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

2. Objectives Overview of Airway Physiology/HFO device interactions that enhance secretion clearance: Equal Pressure Point Dynamic airway compression with flow limitation Clinical uses of positive airway pressure Oscillatory Clearance Index

3. Objectives Types of High Frequency-Assisted Airway Clearance devices and mechanisms of action: Intrapulmonary Percussive Devices –Percussionaire –PercussiveNeb –MetaNeb High Frequency Chest Wall Compression –ThAIRpy Vest –Smart Vest

4. Objectives Types of High Frequency-Assisted Airway Clearance devices and mechanisms of action : Oscillatory Positive Expiratory Pressure Devices (Patient Powered) –Flutter VRP 1 –Accapela Evidence supporting use of the various devices

6. Historical Perspectives Research on many of these devices has been on-going for more than two decades. Eight lectures on airway clearance techniques were presented at the 17 th Annual New Horizons Symposium at the 2001 AARC International Congress and published in Respiratory Care in July, 2002.

7. Historical Perspectives Followed 5 years later with a special Respiratory Care Journal Conference presenting review articles on: Airway Clearance: Physiology, Pharmacology, Techniques and Practice published in Respiratory Care, September and October, 2007.

8. Historical Perspectives Indeed, research continues today. Respiratory Care, March, 2008 –An article by Alves, et al, relate a bench study on performance characteristics of the Flutter at various inclinations and flows.

9. Historical Perspectives Dean Hess, PhD, RRT pointed out in his forward editorial to the Respiratory Care July, 2002 New Horizons Symposium articles and repeated in the Respiratory Care October, 2007 Journal Conference Summary there remains a dearth of high-level evidence related to airway clearance techniques. Studies are plagued with small sample sizes, crossover designs, surrogate outcome measures and statistical concerns.

10. Historical Perspectives However, Hess remains optimistic about these techniques when he states: “Does lack of evidence mean lack of benefit? Is the lack of evidence due to study methodology, or is there really no benefit from many techniques used to enhance secretion clearance? Although we should not be dogmatic about endorsing a therapy with absence of proof of its benefits, we must also not be dogmatic about abandoning a therapy because of absence of proof of its benefit – absence of proof in NOT proof of absence.” D Hess, Respiratory Care July, 2007 Vol 47 No 7 pg 757

11. Airway Physiology/Device Interactions RTs must have an understanding of the principles of airway physiology/device interactions. We must know how a particular device works. Enables us to make appropriate decisions of which device to use under which circumstances.

12. Airway Physiology: Mechanisms of Mucus Mobilization Slug Flow –A semi-solid mucus plug is pushed from behind by expiratory air flow. Annular Flow –Mucus moves along the lumen of the airway by being pulled along by expiratory air flow or transported by cilia. Mist Flow –Aerosolized mucus that is exhaled as suspended droplets. Majority of airway secretion clearance occurs by slug and annular flow Expiratory flow is key to secretion clearance. CD Lapin, Resp Care, July 2002 Vol 47 No 7, p 779

13. Airway Physiology: Equal Pressure Point

14. The EPP concept is integral to understanding how airflow limitation occurs. Initiated at normal lung volumes the EPP lies at the carina or large bronchi which are reinforced by cartilage and thus resist collapse.

15. Airway Physiology: Equal Pressure Point Cough generates supra-maximal, turbulent air flows (flow transients). These flows must speed up through the EPP and creates shear forces that move secretions cephalad. However, the turbulent flows cause faster pressure dissipation creating more potential for airway collapse at the EPP Dynamic airway collapse can also occur in disease states that causes increased compliance (CF, COPD) Even the larger airways may be compressed if frequent coughing has damaged the cartilage.

16. Airway Physiology: Mucus Plugging In order for cough or expiratory flow to mobilize secretions, it is necessary to get air behind the secretions. Mucus plugs can prevent inspiratory flow from getting behind the site of obstruction, making cough and airway clearance ineffective.

18. High-Frequency Devices Anecdotal discoveries made during early research on HFOV found that pulsatile gas flows at 3-30 Hz increased the volume of secretions in the upper airway. Later studies confirmed that the cephalad flow of secretions was accelerated during HFOV. JB Fink, Resp Care July, 2002 Vol 47 No 7 pg 797

19. HFO: Mechanisms of Action Reduction in mucus viscoelasticity. Shear forces at the air-mucus interface applied at oscillatory frequencies that approximate cilia beat frequency. –HFO “resonates” with the cilia, nudging the mucus layer upward. Redistribution of lung volume. JB Fink, Resp Care July, 2002 Vol 47 No 7 pg 798

20. HFO: Mechanisms of Action Normal Exhalation

21. Oscillatory Clearance Index OCI was developed by Scherer, et al, in 1995. Described conditions for optimal mucus transport: –Expiratory flow in the range of 1-3 L/s. –Oscillation frequency between 8-15 Hz. OCI derived to find optimal settings for IPV and HFCO. TA Scherer, Chest 1998; 113; 1020

22. Oscillatory Clearance Index

23. Using surrogate outcomes of weight of expectorated sputum, PFTs and SpO2 they found: High-frequency airway and chest oscillation was as effective as CPT, was well tolerated and has the potential to reduce health-care costs by permitting self-administration of the modalities. TA Scherer, Chest 1998; 113; 1020

24. Optimizing the Oscillatory Clearance Index The higher the frequency, The higher the expiratory flow The lower the inspiratory flow The faster the inward displacement of the airway wall during expiration The slower the outward displacement during the inspiration = Higher OCI Without any bias flow and with equal times of I:E airway wall displacement, the OCI equals zero. TA Scherer, Chest 1998; 113; 1024

25. IPV

26. IPV Waveforms

27. Operational Characteristics Treatment duration approx 20 min. Impaction pressures of 25-40 psig. Frequency < 100 to 225 cycles/min. Non-oscillatory demand CPAP and intermittent mandatory ventilation (mandatory breath control button). Medication Nebulizer

28. PercussiveNeb

29. Operational Characteristics Pressure and flow waveforms similar to Percussionaire. Frequency up to 30 Hz. Medication Nebulizer.

30. MetaNeb

31. Operational Characteristics Pressure and Flow waveforms in CHFO mode similar to other IPV devices. Frequency of 230 cycles/min at 45 cmH 2 O on Higher Setting. Frequency of 190 cycles/min at 38 cmH 2 O on lower setting. CPEP adjustable from 0-30 cmH 2 O.

32. Vest

33. Vest Waveforms

34. Operational Characteristics Pulse frequency adjustable from 5-25 Hz. Pressure in the vest ranges from 28 mm Hg at 5 Hz to 39 mm Hg at 25 Hz.

35. OPEP Devices Flutter VRP1

36. Flutter VRP1

37. Flutter VRP1 Operational Characteristics Variable+15 o L/M 30 60 120 +30 o L/M 30 60 120 Mean Pressure (cmH 2 O) 13 23 55 15 18 42 Mean Resistance (cmH 2 O/L/s) 28 28 25 28 18 20 Mean Frequency (Hz) 22 23 30 25 23 28 Mean Flow Amplitude (L/s) 0.06 0.10 0.16 0.07 0.11 0.16 LA Alves, Resp Care, March 2008, Vol 53 No3 p 319-321

38. Flutter VRP1 Operational Characteristics VariableAW Clearance Effect Best Expir FlowBest Inclination Mean Flow Huff Low Flow and Vol for secretions in distal airways. High Flow and vol for distal airways -30 o + 30 o Mean Pressure PEP 0.2 L/s at PEP of 10, > 1.0 L/s at 20 +15 o / +30 o Oscillation Frequency HFO> 0.2 L/sAll except -30 o Flow Amplitude > 1.4 L/s0 o / +15 o / +30 o LA Alves, Resp Care, March 2008, Vol 53 No3 p 321

39. OPEP Devices: Acapella VariableBlue (Low Flow) Green (High Flow) Mean Exp. Pressure (Cm H2O) 3-246-21 Pressure Amplitude (cmH2O) 3-111-12 Oscillatory Frequency (Hz) 8-2513-30 TA Volsko, Resp Care, Feb, 2003 Vol 48 No 2 pg 127

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

42. Stabilizing Airway with PEP

43. Thank You for your participation! Discussion Presentation available at: www.rtconnection.org david.barton@HCAHealthcare.com