Background: For patients with cystic fibrosis, thick secretions cause a need for bronchial hygiene therapy. We tested three percussive devices that are designed for secretion mobilization to determine the most efficient product: The IPV (Model IPV-1C, Percussionaire, Sandpoint, ID), MetaNeb (Hill-Rom, St. Paul, MN), and Vortran PercussiveNEB (Model 2.0, Vortran Medical Technology, Sacramento, CA). Our null hypothesis is that the three devices will show no significant difference in rate of mucus velocity when compared. Methods: An ASL 5000 lung simulator (Ingmar Medical, Pittsburgh, PA) was set to simulate a cystic fibrosis patient with a Cstat of 45 cm H2O, Raw of 17 cm H2O/L/s, VT 800 mL, f 15, and I:E ratio 1:2. To create the airway, a 10 mm I.D. x 30 cm clear plexiglass tube was attached to the ASL 5000 and each device was attached to the distal end of the tube. A hole was drilled in the center of the tube to accommodate a 10 mL syringe. For the mucus simulant, two parts of Aquasonic 100 Ultrasound Transmission Gel (Parker Laboratories Inc., USA) was mixed with three parts of water. This mixture’s viscosity has been documented to be in the same range of human sputum. For each run, 1 mL of mucus simulant was injected into the center of the leveled plexiglass tube and allowed to settle for one minute. Each device was set to run for 30 seconds at the highest and lowest frequency setting for 5 trials. The best three out of the five trials were used in the mean for the conclusion. A photograph was taken at the end of each trial using a 12 megapixel camera. We set the starting point for the measurement at the distal leading edge of mucus once settled and measured the amount of forward or backward movement after the trial was completed in centimeters via ruler and pixel measurement. Results: The IPV produced forward movement of +10.67 cm on the high frequency setting and +6.12 cm on its low frequency setting. The MetaNeb’s average was - 0.02 cm on low frequency and - 0.14 cm on high frequency. The Vortran PercussiveNEB’s average on the low frequency setting was - 0.79 cm and - 16.76 cm on the high setting. Conclusions: We rejected our null hypothesis because there were significant differences between the three devices. The MetaNeb and Vortran PercussiveNEB both produced negative caudad movement on both high and low frequency settings. The IPV produced forward cephalad movement on both high and low frequency settings. During use of the IPV, secretion movement is best when set at its highest frequency.

Background: The COVID-19 pandemic presented an array of challenges across healthcare, notably critical care staffing models. The potential for mechanical ventilation (MV) to be managed in part by practitioners unaccustomed to doing so revealed the need for basic and applicable education. Detailed online modules and quick-reference document formats emerged to bridge knowledge gaps. A one-page primer for MV was developed and widely disseminated. Methods: A panel of experts composed of respiratory care clinicians, educators, and managers developed a bedside MV reference intended to aid clinicians who were assisting in the MV management of COVID-19 patients. Mean respiratory care experience amongst the panel was 22 years (11-31). The panel developed the MV reference based on evidence-based practice, consensus guidelines, and ventilator platform configurations. The MV reference summarized initial ventilator settings and assessment-based adjustments as well as recommended ARDS guidelines. A glossary of commonly used terms and modes of ventilation was also included. Results: The MV reference was distributed via social media (Twitter, Facebook, LinkedIn). According to available analytics, social media posts were viewed 46,745 times and the MV reference attachment was opened 2,815 times. It is unclear from available analytics how many times it was downloaded. The MV reference was also posted to the AARC’s clinical resource page, AARC Connect, and SCCM Connect. The AARC’s “Mechanical Ventilation for COVID-19 Video Series” webpage, on which the MV reference was posted, showed 34,501 site visits, though data relevant to downloads of the MV reference specifically was not available. Data relevant to views associated with AARC Connect or SCCM Respiratory Care Section as well as institutional utilization were unavailable. Our data is inconclusive and limited since we could not analyze which specific information was accessed or if our document was downloaded; nor did we intend to collect outcomes. Conclusions: Quick reference educational tools and just-in-time learning can be developed and disseminated rapidly in times of crisis. Attention to evidence-based practice and expert experience in the development of these tools ensures appropriate guidance. More research is needed to assess the effects these educational efforts have on outcomes.

Background: IPV is used by some as a treatment option for atelectasis and mucus clearance in patients. The goal of this study is to assess different mask types, securement methods, and their impacts on pressure amplitudes (∆P) and mean airway pressure (MAP). Given that the device has a wide range of frequencies, we will assess the low and high frequency to create an impact range. Our hypothesis is that the ∆P and MAP of the percussive device is not dependent on the type of mask or securement method that is utilized. Methods: The IPV from PercussionAire (Sand Point, ID) was set to Demand CPAP/PEEP off, Insp. Flow to max, and Insp. time to neutral. The phasitron was then connected to an IngMar Medical (Pittsburgh, PA) ASL 5000 Active Servo Lung and set to passive lung settings and a COPD profile (CS 55 mL/cm H2O, RAW 22 cm H2O/L/s). Measurements of average PIP, PEEP, and MAP were recorded for two frequencies (high and low). For the low frequency run, the IPV was set to the lowest frequency, placed on the ASL for 1 min, measurements recorded and repeated 4 times. IPV then changed to highest frequency and measurements recorded 5 times. The different user interfaces were the BiPAP PerformaTrak Full Mask (Respironics, Murrysville, PA) using provided straps, BiPAP mask held on Mannequin head by researcher to assure no leak, Ambu Spur II (Ambu, Glen Burnie, MD) mask held on head. The three user interfaces were tested on both the high and low frequencies. Results: After averaging PIP and PEEP for all five trials, the ∆P was then calculated for each of the user interfaces at low and high frequencies. The ∆P on low frequency using the strapped BiPAP was 10.48, held BiPAP 13.2, and Ambu masks 9.6 cm H2O respectively. ∆P on high frequency using the strapped BiPAP was 8.62, held BiPAP 9.41, and Ambu masks 8.65 cm H2O respectively. MAP on low frequency using the strapped BiPAP was 4.14, held BiPAP 5.63, and Ambu masks 4.08 cm H2O respectively. MAP on high frequency using the strapped BiPAP was 3.99, held BiPAP 4.39, and Ambu masks 4.22 cm H2O respectively. Conclusions: Of the mask selection and securements studied, the held BiPAP mask delivered the greatest average ∆P and MAPs to the carina in both low and high frequencies. There was a difference in mask selection as opposed to our original hypothesis; however, further research is needed to determine clinical significance of these differences and their impacts on atelectasis and secretion removal.

Background: Patients with tracheostomies are often required to be medically treated with high flow oxygen therapy as well as nebulized medication. ConMed Corporation’s MUNODA Universal Respiratory Adapter (Utica, NY) allows healthcare providers to eliminate the need to disconnect high flow oxygen by delivering both inhaled medication and high flow oxygen to the patient simultaneously. The purpose of this research is to determine if using this adapter impacts the amount of medication delivered to the airway. We hypothesized that there would be no difference in solute deposition between using the MUNODA Universal Respiratory Adapter (Y-tube adapter) combining a high flow device and nebulizer versus a traditional treatment delivered via aerosolized nebulizer alone to deliver nebulized medication. Methods: A simulated patient with a 7.0mm Shiley Tracheostomy Tube (Tyco Healthcare, Minneapolis,MN) was ventilated by a Hans Rudulph Series 1101 Breathing Simulator (Shawnee Mission, KS) utilizing a normal breathing pattern. For the trials with the Y-piece-tube adapter, a Salter Labs NebuTech HDN nebulizer (Arvin, CA) and a Carefusion Venturi high flow device (San Diego, CA) were attached to the Munoda y-tube. The y-tube was then attached to the trach via a t-piece with an exhalation port using large bore tubing measuring one link. A Teleflex Bacterial/Viral Filter (Morrisville, NC) was attached to the airway and connected via large bore tubing to the breathing simulator. A 3-mL solution of 10% hypertonic saline solution was nebulized for 4 minutes. The Venturi device was set to deliver a total flow of 32 L/min. For the trials without the Y-piece-tube adaptor, a nebulizer was placed directly into the t-piece. Each filter was weighed before and after the treatment was given, and the difference was recorded. Each trial was performed in triplicate. Results: The average change in weight of the filters following nebulization utilizing the Y-piece adapter and high flow O2 was 26.7 mg, and the nebulizer alone was 70 mg. The difference in weight between the two trials was significant (P = .015). Conclusions: Based on the results from these trials, using the Munoda adapter with high flow O2 delivered significantly less aerosol than the T piece method. We discovered an incidental finding; when the nebulizer and high flow Venturi were used with the Y- piece, it generated less visible aerosol than when the nebulizer was used alone.

Background: The Procedural Oxygen Mask (POM) is a multiport mask that is designed to allow scopes, probes, and tubes through the mask and into the mouth or nose while claiming to deliver high levels of oxygen. The goal of this study was to determine the actual O2 delivery at the carina while wearing the POM mask at different flows, breathing patterns, and integrity of the masks oral access membrane. Our hypothesis is that there will be no difference in O2 delivery at the carina from the POM based on breathing pattern, flow, or status of the POM masks oral membrane. Methods: A bench model was created by adapting an adult intubation manikin (Armstrong Medical Industries, Lincolnshire, IL) to an Ingmar Medical ASL 5000 (Pittsburgh, PA) breathing simulator. Tygon tubing and appropriate adapters connected the manikin’s trachea with the breathing simulator’s outlet so that as the simulator operates, air flows in and out through the manikin’s mouth and nares. A TED 60T O2 analyzer was connected to the simulated carina of a mannequin. The POM was secured to the face of the mannequin with manufacturer provided equipment and connected to an O2 flow meter. The lung simulator was set at respiratory rates of 6, 12 and 25 breaths/min, and tidal volumes were set at 300 mL, 600 mL, and 925 mL, respectively. The flow meter was set to a flow of 10, 12, or 15 L/min with the manufacturer provided high flow adapter. The FIO2 was measured by the analyzer for each breathing pattern. First with the membrane of the mask completely intact, then with a bronchoscope inserted with the aid of 0.045 oz PDI lubricating jelly, and lastly post mock bronchoscopy with membrane no longer intact. The O2 analyzer was calibrated between each reading. Results: Statistical difference was found in the mean delivered FIO2 between breathing patterns, flow meter settings, and if the masks membrane was intact. However, after the membrane is perforated the patients breathing pattern and O2 flow are the primary factors that impact FIO2 delivery. Average range of delivered FIO2 across all runs was 38-84%. Conclusions: Delivered FIO2 varied from 38-84% using the POM mask. The FIO2 delivered by the POM mask is impacted by breathing pattern, flow of oxygen and intactness of membrane. During clinical use providers should be aware of this range and how these factors will impact the delivered FIO2.

Background: A variety of pulmonary conditions can lead to increased mucus production that can become tenacious and difficult to mobilize. Percussive devices such as the Intrapulmonary Percussive Ventilator (IPV) (Model-2C, Percussionaire Sandpoint, ID) and MetaNeb system (Hill-Rom, St. Paul, MN) are marketed as devices that assist in mobilizing secretions. The purpose of this study is to determine if coaching patients to achieve a specific I:E ratio will assist in secretion mobilization while using these devices. Methods: The Ingmar Medical ASL 5000 (Pittsburgh, PA) was used to simulate a spontaneous breathing patient with active exhalation. The simulator was programmed with a compliance of 60 mL/cm H2O, resistance of 18 cm H2O/L/s to represent chronic bronchitis, with a tidal volume of 800 mL and a respiratory rate of 15. Three I:E ratios were used to represent different breathing patterns: 1:3 (normal spontaneous breathing), 3:1 (inverse), and 1:1 (equal). Both IPV and MetaNeb were used for testing. Each device was tested on its high frequency and low frequency settings. For the mucous simulant, 100 mL of locust bean gum solution (1.9 g LBG/500 mL Water) was mixed with 3 mL of sodium tetraborate solution (8 g Tetraborate/1 L water). A 33.2 cm long section Tygon tubing with an internal diameter of 13 mm was used to simulate the trachea. For each trial, 1 mL of mucous simulant was injected into the middle of the tubing. Each I:E ratio and frequency setting was performed in triplicate. The velocity was calculated in centimeters per minute (cm/min) using picture analysis on ImageJ software (National Institute of Health, Bethesda, MD). Results: There was no difference in mucous velocity between devices (P = .53) or frequency setting (P = .38). There was, however, a significant difference in mucous velocity between I:E ratios, with the largest difference occurring between a ratio of 3:1 and 1:1 (P =

Background: Patients with respiratory complications requiring further interventions, such as tracheostomies, often also need routine medications as a part of their care plan. Many of these respiratory medications are delivered in aerosol form via small volume nebulization. The purpose of this study is to determine how the SouthMedic Oxytrach mask (Barrie, Ontario, Canada) aerosol delivery compares to the aerosol delivery of the Teleflex Hudson RCI Trach mask (Morrisville, NC). We hypothesized that there will be no difference in aerosol delivery between the Oxytrach mask and the Hudson mask. Methods: An adult model with a Medtronic 8.0 mm Shiley tracheostomy tube (Minneapolis, MN, US) was attached to a Hans Rudolph, Inc. Series 1101 breathing simulator (Shawnee Mission, KS, US) set to achieve a 500 mL tidal volume, with 16 breaths/min, Raw 5.0 cm H2O/L/s, Compliance 80 mL/cm H2O, and 33% IT. A Teleflex Bacterial/Viral Filter (BFE: 99.999+%, VFE: 99.99+%) (Morrisville, NC, US) was placed distal to the tracheostomy tube on the right main stem bronchi of the model and proximal to the breathing simulator with the left main stem bronchi occluded. For each trial, 6 mL of 10% hypertonic saline solution was nebulized via the Vyaire Medical AirLife Misty Fast nebulizer (Mettawa, IL) at 8 L/min for 4 min. A filter was weighed prior to nebulization, the weight was recorded, and the filter was placed in line on the model. In the first three trials, the nebulizer was attached to the Oxytrach mask and after nebulization; the filter was re-weighed and recorded. In the last three trials, the Hudson masks were used. Results: The mean post-nebulization weight of the filters with the Hudson mask was 270 mg. The mean post-nebulization weight of the filters with the Oxytrach mask was 20 mg. There was a statistically significant difference in the amount of aerosol delivery between the two masks (P= .008). Conclusions: Based on the results, it was found that the Hudson mask had significantly more aerosol delivery to the filter than the Oxytrach mask. There was an incidental finding during the nebulization trials with the Oxytrach mask. The mushroom shaped Pin and triangular directional Diffuser inside the Oxytrach mask, when placed on the model, fit directly inside the opening of the tracheostomy tube, causing the potential for airway occlusion.

To the Editor: I would like to thank the authors for bringing to light the need for further education on airway pressure release ventilation (APRV) and how to manage this mode of ventilation.[1][1] However, for Miller, Gentile, Davies, and MacIntyre to state that “there is only limited consensus

Background: In airway pressure release ventilation (APRV), there have been questions about whether increases in pressure low (Plow) will impact flow characteristics while maintaining a time low (Tlow) of 75%. We hypothesize that the addition of Plow will not change the flow characteristics. Methods: Utilizing the Hamilton G5 (Bonaduz, Switzerland) and Drager V500 (Lubeck, Germany) mechanical ventilators, we created a baseline with the following settings: High pressure (Phigh) 20 cm H2O, low pressure (Plow) 0 cm H2O, time high (Thigh) 6 s, time low (Tlow) 75% of peak expiratory flow (PEF). Intrinsic PEEP and the change in pressure from Results: The addition of Plow resulted in a expiratory flow decrease of 12 L/min on both ventilators from a Plow of 0 to 20 cm H2O. the tidal volumes increased by almost triple even while maintaining the same ΔP. Additionally, the increases in PEEP did not simply increase by the same number in Plow. Conclusions: With the addition of Plow, flow characteristics did change, the intrinsic PEEP increased by unpredictable values, and the VT increased by almost triple despite maintaining the same ΔP. The addition of Plow does impact the flow, VT, and intrinsic PEEP in patients and caution should be taken when applying it to APRV.

Background: Monitoring pressure while ventilating patients using manual resuscitation devices is important to prevent lung injury and gastric inflation. Our goal for this study is to determine whether each device9s pressure manometer reading is accurate when compared to what is being measured inside the lung. Our hypothesis is that there will be no difference between the pressures on the manometers and the four targeted pressures, also there will be no difference between each device. Methods: A model composed of a single adult Michigan Instruments Test lung with a compliance of 0.015 (L/cm H2O), a 22-mm adapter in line, and a Michigan Instruments Pneuflo Resistor of 5 (cm H2O/L/s) was used to test each device. A software program called Pneuview3 was used to graph delivered pressures over time inside the test lung. A single investigator static held each device until the graph on the Pneuview3 software remained constant for two seconds, while targeting pressures of 10, 20, 30, and 40 cm H2O with 0 PEEP. Three trials were conducted for each device at the four targeted pressures. The devices that were used include the Air Flow Manual Resuscitator/Ventilator (Vent Lab, Grand Rapids, MI), the Adult BVM, the Neo-Tee, and Reusa-Tee T-Piece Resuscitators (Mercury Medical, Clearwater, FL) and the Neo-Puff T-Piece Resuscitator (Fisher & Paykel, Tamaki, New Zealand). Results: All resuscitation device pressure manometers were significantly different from one another (P=.001), except the Neo-Tee and NeoPuff (P=. 137). The pressure manometer on the Reusa-Tee by Mercury Medical tested to be the most accurate of all devices tested with an average of 1.01 cm H2O difference than the targeted pressures. The Vent Lab BVM tested to be the least accurate of all devices tested with an average of 8.65 cm H2O difference than the target pressures. In general, accuracy decreased as ventilating pressure increased. Conclusions: All devices tested had a less than 5 cm H2O difference than the targeted pressure except the Vent Lab BVM. The majority of the devices manometers proved to be accurate when targeting the four specific pressures. Having an accurate pressure manometer helps clinicians insure that proper ventilation of the lungs is occurring while minimizing hazards and complications.

Background: Bench studies reported as abstracts in 2006 and 2010 demonstrated that not all ventilators report accurate lung compliance measurements. The purpose of this study was to compare a set compliance (Cs) on a Michigan test lung to the measured Cs on four new generation ventilators not previously studied. Methods: The ventilators tested were the Drager v500, ServoU, PB 980, and Hamilton G5. The ventilators were set to volume control mode with a tidal volume of 500 mL, respiratory rate of 12 breaths/min, PEEP of 0 cm H2O, and an inspiratory time of 1 second. The ventilators were individually attached to a single lung Michigan test lung (Grand Rapids, Michigan). Compliance on the test lungs were set to 30, 60, and 90 mL/cm H2O respectfully and verified with a Med Graphics 3L Syringe per manufacturer9s guidelines. Each time the compliance was changed the setting was verified per manufacture guidelines. Each ventilator was attached to the test lung at the different Cs settings and the ventilators reported Cs value were recorded three different times, 2 min apart. The reported values from the ventilator were then compared to the set values of the test lung. Results: All of the ventilators reported lung compliances within 2 cm H2O of set and verified compliances Conclusions: In this bench test, we found that all new generation ventilators reported accurate lung compliances. This is different than prior abstracts that found that some ventilators were not as accurate on their reported Cs values.