EzPap at different I:E ratios and how they affect hemodynamics

1. EzPap at different I:E ratios and how they affect hemodynamics Research Team: Michelle Emison Kim Nguyen Edinah Isoe Raquel Smith Ade Adeoso Lorraine Gonzales Faculty Advisor: Kelley Buzbee, AAS, RRT-NPS, RCP

2. Biological Question Will EzPap at different I:E ratios affect the hemodynamics of a healthy adult?

3. Hypothesis EzPap at a pressure of 15 CmH2O with different I:E ratios will cause physiological changes in the hemodynamics of an adult test subject.

4. Abstract • To determine the effects of EzPap at different I:E ratios on the hemodynamics on healthy adults ( n= 10.) Instructions on the procedure was given after consent forms were signed. • The subjects’ baseline heart rate, respiratory rate, Spo2, pulse and Blood Pressure were recorded. Test subjects were instructed to take a few breaths off device to set the therapeutic pressure at 15 cmH2o. Test subjects were given 2 minutes between each I:E ratio. • Vital signs were then recorded after each I:E ratio.

5. Abstract continued We did find some hemodynamic changes but nothing significant or consistent. Heart rates and respiratory rates increased slightly but not in all patients and nothing clinically significant.

6. Cohort Group

7. Cohort Group

8. Background • EzPAP is an easy to use and inexpensive device that provides positive airway pressure on inhalation, exhalation and on breath hold. The resulting action is a positive inspiratory airway pressure as well as positive expiratory airway resistance. The resistance provides collateral ventilation to the airways and creates the backpressure needed to open up collapsed alveoli. According to Continuing Medical Education Corner, this therapy is very helpful in test subjects at risk for developing post-operative atelectasis, as well as the treatment of atelectasis and has also shown effective in lung expansion therapy.

9. Background con’t. Contraindications include: • test subjects who cannot tolerate increased WOB • test subjects with 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 • respiratory alkalosis • nosocomial infections • untreated tuberculosis (EzPAP clinical performances)

10. Glossary • Atelectasis: an abnormal condition characterized by the collapse of alveoli, preventing respiratory exchange of carbon monoxide and oxygen in a part of the lungs. • Bilateral breath sounds- sounds of the heart and lungs • Blood pressure-force exerted against the walls of blood vessels • 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, violent sneezing, fragility of the mucous membrane or of the arterial walls, chronic infection, trauma, hypertension, leukemia, vitamin K deficiency, or most often, picking the nose.

11. Glossary con't. • 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 • Intrathoracic pressure- pressure in the chest cavity • Neuromuscular disorder: disorder affecting both nerve and muscle tissue. • Nosocomial infections: an infection that is acquired at least 72 hours after hospitalization

12. Glossary con’t. • Oxygen enrichment: Term often used to describe the oxygen level is greater than in air. • Oxygen Saturation- A measurement of the current percentage of oxygen carried in the blood at a given time • Oxygen therapy: the inhaling of oxygen under pressure, often inside a pressurized chamber, as a treatment for respiratory conditions. • Pneumothorax: collection of air or gas in the pleural space causing the lung to collapse • Preload – The amount of pressure stretching the ventricular walls at the onset of ventricular contraction. • 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

13. Glossary con’t. • Respiratory arrest: the cessation of breathing. • Restrictive lung defect: incomplete lung expansion and increased lung stiffness • Stroke volume- volume of blood ejected from the ventricle during contraction. • Systolic blood pressure- blood pressure when the heart is working • Temperature-warmth or coldness of the body • Therapeutic- a medical treatment used to remediate a health problem that has been diagnosed. • Venous Return: the return of the blood to the heart via the vena cava and coronary sinus

14. Methodology • EzPAP is indicated for test subjects who need lung expansion therapy to prevent or reverse atelectasis; it can be used as prophylactic or therapeutic device in atelectasis. It can also be used with test subjects with restrictive lung defects, hypercapnia secondary to decreased lung tissue, test subjects at risk for developing pulmonary atelectasis. EzPAP is also intended to optimize delivery of inhaled bronchodilator. The EzPAP can also be used in the removal of excessive mucus from the lungs in cases of test subjects with a history of pulmonary problems like cystic fibrosis, bronchiectasis and lung abscess and thus potentially limiting the bacterial burden and decreasing swelling in the conducting airways.

15. Methodology con’t. • First the subjects were placed in a comfortable position while baseline heart rate, respiratory rate, Spo2, pulse and Blood Pressure were all recorded. Then the test subjects were instructed to take a few Breaths off of the EZ Pap device to set the therapeutic pressure at 15 cmH2o. Then the test subjects were expected to rest two minutes prior to the initiation of tests. • After the subjects rested they were instructed when to inhale and when to exhale which was at an I:E ratio of 1:3. The I:E ratio was timed with a clock with a second hand. The test subject continued this for 2 minutes, then Heart rate, respiratory rate, pulse, blood pressure, and SpO2 was measured. • The test subjects were then instructed to rest for two minutes before initiating the next test. The test subjects were again told to sit comfortably in a chair and were instructed when to inhale and when to exhale to set a I:E ratio of 1:4. This was continued for 2 minutes then vital signs again were measured. A period of rest ensued again for 2 minutes, before the next test began at an I:E ratio of 1:5.

16. Methodology con’t. • The entire procedure was carried out using an EzPap with a mouthpiece, bacteria filter, pressure monometer, O2 flow meter, blood pressure cuff, sphygnomometer, pulse oximeter, and a stethoscope. • EzPap was only used once and disposed of after each test subject.

17. RAW DATA

18. INITIAL VITAL SIGNS

20. Post Vital SignsI:E Ratio of 1:2

21. Post Vital SignsI:E Ratio of 1:3 * XX indicates unable to complete

22. Post Vital SignsI:E Ratio of 1:4 * XX indicates unable to complete

23. The % change in the respiratory rate of the 10 test subjects with an I:E ratio of 1:2 was 7.696% The % change in the heart rate of the 10 test subjects with an I:E ratio of 1:2 was 3.835%

24. The % change in the respiratory rate of the 10 test subjects with an I:E ratio of 1:3 was 15.406% The % change in the heart rate of the 10 test subjects with an I:E ratio of 1:3 was 0.209%

25. The % change in the respiratory rate of the 10 test subjects with an I:E ratio of 1:4 was 4.587% The % change in the heart rate of the 10 test subjects with an I:E ratio of 1:4 was 5.589%

26. Discussion • The research project did have its limitations. There were not enough test subjects that were readily available to give us a larger and more detailed view of the effects on hemodynamic at different I:E ratios. All test subjects were healthy so we were unable to study the effects of Ezpap on hemodynamics of persons with obstructive or restrictive defects. There was also not enough supplies due to funding and time was also another factor that is taken into account. A bourdon gauge monometer was used, it might be interesting to see what would have happened with a digital monometer. Pressure waveform was not measured and flow wave forms were also not measured due to lack of equipment.

27. Discussion • Respiratory rate showed a higher % change than any other vital sign measured. • Heart rate also showed a slight increase but was not as significant as the respiratory rate. • No consistancy was found with Blood pressure. • O2 sats stayed within normal limits.

28. Conclusion We did find some hemodynamic changes but nothing significant or consistent. Heart rates and respiratory rates increased slightly but not in all patients and nothing clinically significant. It would be difficult to make generalizations about ezPap and patients’ VS because the number of test subjects was too small.

29. DiscussionNew Biological Question It would be nice to: See someone repeat this study with an obstructive or restrictive defect such as asthma, COPD, someone with increase RAW or decreased compliance, and atelectasis. To have a digital monometer as opposed to the bourdon gauge monometer. To see the waveforms measured while using the Ezpap.

30. References • Agra, Melbourne, Pune (2009). Introduction to mechanical ventilation. Retrieved on February 2, 2009 from http://www.aic.cuhk.edu.hk • 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 • Bach, J.R. Dr. Bach’s Articles. Retrieved on January 31, 2009 from www.doctorbach.com • 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 • Chang, David (2006). Clinical Application of Mechanical Ventilation. Thomson Company. • 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 • European Industrial Gases Association. Retrieved on January 30, 2009 from www.iega.org • 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. • R.L Wilkins, R.L Sheldon, S.J KriderClinical Assesment in Respiratory Therapy, fifth edition 2000 (Pg 48-60) • Robert L. Wilkins, Robert M. Kacmarek, James K. Stoller. Egan’s Fundamentals of Respiratory. Mosby Inc 2008 (Pg 831-832)