Diapositiva 1

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From Research to Clinical Practice How the
Innovation May Improve the Thoracic Surgeons
Skill
Cosimo Lequaglie Dpt. of Thoracic
Surgery IRCCS-CROB Cancer Center Rionero in
Vulture, ITALY
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Nowsadays the evolution...
Surgical technique is evolved and the available
means can allow an effective and safe
postoperative chest drainage.
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The digital chest tube airflowmeter AIRFIX
TEUPs Ltd., Deutshlandsberg, A, 2002
A data acquisition system digitizes the output
signal of a mass airflow sensor and
continuously sends measurement values to a
processor. Only the netto flux into one
direction is recorded as air-leak. The amount of
air moving into the opposite direction (shift of
intrapleural dead space) is subtracted from the
leakage. Sensor parameters are stored in the
Elettrically Erasable Memory Area (EEROM) of a
microcontroller
Anegg U, Lindenmann J, Matzi V et al., AIRFIX
The first digital postoperative chest tube
airflowmetry A novel method to quantify air
leakage after lung resection. Eur J Cardiothorac
Surg 200629867-872
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Digi VentTM - Millicore AB, Danderyd, Sweden
b
a

• Controller Unit Micro Electronic Mechanical
  System (MEMS) sensors providing a digital
  measurement and recording of air flows
  (mlmin-1/lh-1) and pressures maximum, minimum,
  differential (peMAX- piMIN) (cmH2O).
• Controller single use only.
• Liquid Crystal Display showing measurement data
  at the bedside of the patient real time
  (instantaneous) flows (up) and pressures (down),
  1-3-6 hours airflow averages.
• The Controller Unit recorded data every 2 min.

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Digi VentTM - Millicore AB, Danderyd, Sweden

• COLLECTION CHAMBER
• Canister capacity 2000 ml
• One-way dry valve
• Pressure reducing valve
• Mechanical suction regulator
• Liter/hour air flow accumulation button
• Flashing hi/lo pressure alarm (gt 5 cm H20 lt - 40
  cmH20)

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Digi VentTM More Advantages

• The C.U. displays real time flow and pressure
  readings, but the data downloaded in Excel are
  the last actual measured readings in 2 minutes
  increments.
• The data on the Controller Unit are not erased by
  the download process.
• One, three and six hours air flow averages
  displayed on the C.U. just while attached to the
  collection chamber.
• Graph form of C.U. data images are automatically
  saved as jpeg files.

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a
b
Air leak in the same patient the progressive
divergent pressure curves anticipates the visual
appearance of the air leak. The curves show the
expiratory (dark blue) and inspiratory (blue)
pressures. You can observe an initial interspace
among ep and ip in the first 12
post-operative hours (p.o.) after a preassure
plateau, and finally a progressive divergence of
the curves from the 2nd p.o. day (a) the
superior curve (electric blue) shows the
differential pressure (?p ep-ip) (b) the
superior curve (yellow) underlines an air leak in
the first 12 hours, no leak until to the 3rd p.o.
day, and a late leak anticipates from a
differential pressure in increase.
Rita Daniela Marasco, Gabriella Giudice, and
Cosimo Lequaglie. How to distinguish an active
air leak from a pleural space effect. Asian
Cardiovasc Thorac Ann 201220682-688
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a
b
So-called pleural space you can observe a great
differential pressure in a (blue electric)
without air leak in b (yellow curve). Large
swinging endopleural pressures (?pgt25 cmH2O) for
poor elastic serosa in empyema and pleural
effusions.
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Increasing air leak gt500 ml/min
The converging curves show the complete
re-expansion of the lung and the possibility to
remove the chest drain
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b
a
Obstructed clot drain in the same patient from
the 1st p.o. day, sudden reduction of the
differential pressure (blue electric) and
convergence of e.p. and i.p. curves in low (dark
blue and blue). a) this corresponds to the
disappearance of air flow (yellow) after an
evident air leak at the beginning b) this
happens when there is an obstruction of the chest
tube, to example from clot in the drain or
kinging during the night.
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ATMOS E201 Thorax - MedizinTechnik, Lenzkirch,
Germany

• Measurement and recording air flows (l/min).
• Vacuum unit on defalult negative pressures (-5 up
  to -100 cmH2O).
• Rechargeable battery up to 12 hrs
• Canister capacity 2000 ml
• Pump off mode not provided.
• Water seal valve available.

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THOPAZ - Medela, Baar, CH
a

• INTELLIGENT THERAPY
• OPTIMIZED CARE
• The 1st digital chest drain with portable suction
  pump and downloading data on board

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The 1st DRENTECH REDAX had an adjustable vacuum
control unit with a water seal chamber and an
obvious analogue detection. In any case with a
sucking pump.
a
The DRENTECH MOBILE REDAX had an adjustable
vacuum control unit with a water seal chamber and
an obvious analogue detection. All time
visibility for air leak monitoring. Capacity
volume 2550 ml. Sucking pump from -10 up to -60
cmH2O.
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DRENTECH PALM REDAX

• Measurement and recording air flows (ml/min) and
  endopleural pressures (cmH2O), until 99 hours.
• Vacuum unit on default negative pressures (-10 up
  to -60 cmH2O).
• Pump off mode not provided.
• Water seal valve available.

Speedy passage
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DRENTECH PALM EVO REDAX

• Detection and recording air flows (ml/min) plus
  endopleural pressures (cmH2O or KPa), until 99
  hours. Mini USB-key port.
• Vacuum unit on default negative pressures (-10 up
  to -60 cmH2O).
• Rechargeable battery up to 36 hrs
• Pump off mode provided.
• Water seal for the collection chamber.

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Characteristics of the digital devices mostly
profits the postoperative clinical evaluation
Value of real time air leak (up-date every
minute). This parameter is the quantification
of the bubbles that the surgeon is usual to
appraise in the box with water valve. The
advantage consists in the objective evaluation of
the leak, without the usual problems owed to the
subjective interpretation of the quantity and
frequency of the bubbles. Value of the
intrapleural pressure (measured on board) in
real time. This measurement represents the
equivalent of the excursion of the meniscus in
the water valve. The pressure trend is visualized
in graphic format with an oscillating bar on the
display. The variations follow the each
respiratory acts of the patient. Mean value per
hour of the air leaks, adjourned every hour.
Such parameter represents an important help of
evaluation because it shows a clear and objective
evaluation of the air leak, without the trouble
of the inevitable variations caused by many
istant factors. These values are memorized and
revisable for 99 hours directly on PALM EVO.
Course of the air leak and the intrapleural
pressure in graphic format. This possibility is
useful to appraise to glimpse the evolution of
the 2 parameters in the time.
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Characteristics of the digital devices mostly
profits the postoperative clinical evaluation
Value of the air leaks in real time (up-date
every minute). This parameter is the
quantification of the bubbles that the surgeon is
usual to appraise in the box with water valve.
The advantage consists in the objective
evaluation of the leak, without the usual
problems owed to the subjective interpretation of
the quantity and frequency of the bubbles. Value
of the intrapleural pressure (measured on
board) in real time. This measurement
represents the equivalent of the excursion of the
meniscus in the water valve. The pressure trend
is visualized in graphic format with an
oscillating bar on the display. The variations
follow the each respiratory acts of the
patient. Mean value per hour of the air leaks,
adjourned every hour. Such parameter
represents an important help of evaluation
because it shows a clear and objective evaluation
of the air leak, without the trouble of the
inevitable variations caused by many istant
factors. These values are memorized and revisable
for 99 hours directly on PALM EVO. Course of the
air leak and the intrapleural pressure in graphic
format. This possibility is useful to appraise
to glimpse the evolution of the 2 parameters in
the time.
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Characteristics of the digital devices mostly
profits the postoperative clinical evaluation
LLL air leak air flow ml/min
Value of the air leaks in real time (up-date
every minute). This parameter is the
quantification of the bubbles that the surgeon is
usual to appraise in the box with water valve.
The advantage consists in the objective
evaluation of the leak, without the usual
problems owed to the subjective interpretation of
the quantity and frequency of the bubbles. Value
of the intrapleural pressure (measured on
board) in real time. This measurement
represents the equivalent of the excursion of the
meniscus in the water valve. The pressure trend
is visualized in graphic format with an
oscillating bar on the display. The variations
follow the each respiratory acts of the
patient. Mean value per hour of the air leaks,
adjourned every hour. Such parameter
represents an important help of evaluation
because it shows a clear and objective evaluation
of the air leak, without the trouble of the
inevitable variations caused by many istant
factors. These values are memorized and revisable
for 99 hours directly on PALM EVO. Course of the
air leak and the intrapleural pressure in graphic
format. This possibility is useful to appraise
to glimpse the evolution of the 2 parameters in
the time.
? Pleural Pressures cmH2O
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Because our Cancer Research Institutetesting all
the digital thoracic drains has chosen and
modified PALM EVO
Extreme simplicity of use The digital drain
has been inserted in the routine use with very
brief learning curve, both for the surgeon and
the nurse. Such characteristic is facilitated by
the presence of the unidirectional water valve
that allows always the analogical evaluation of
the leaks. Availability of all the necessary
information to the management of the patient in
postoperative period They are directly present
and utilizable on the instrument for 99 hours
(over 4 days) from the beginning of the drain. It
is not necessary to effect some transfer of the
data to a PC such possibility is optional for
following elaborations or for the recording. It
is a true chest drain Good ability of
collect, water valve, handle for the transport
and the fixing. Versatility of the tool that
allows, in every moment, to be able to work in
aspiration or in real gravity or, even, to be
connected to the aspiration checked to wall this
is a great advantage if it is considered that the
thoracic patient can be transferred often for
other diseases or complications to other
departments.
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What does it mean that PALM EVO works in real
gravity ?
Today the devices on the market don't allow the
digital drain for gravity, there is always a
certain aspiration. This last, to practice an
effect on the pleural cavity, doesn't allow
further the evaluation of the excursion of the
intrapleural pressures. The Pump-off
function of the PALM EVO allows to eliminate
whatever intervention from the aspirant pump the
drain proceeds completely to gravity. The air
coming from the patient is expelled through a
special valve for which the drain is always
active without any risk for the patient.
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Why to know the trend and the value of the
intrapleural pressure ?
? Pleural Pressures cmH2O
RIGHT LOWER LOBECTOMY (carcinomatous abscess of
the lung)
The intrapleural pressure is related to the
pulmonary expansion in the pleural cavity. In the
traditional systems, such parameter is entirely
appraisable in real time observing the meniscus
of the water in the unidirectional valve.
Increased excursions are usually related to the
presence of a real pleural space in the chest,
usually caused by an incomplete pulmonary
expansion. The PALM EVO device allows to
appreciate the trend of such pressures during the
whole postoperative period the maximum and
minimum pressure trend has contemporarily shown
on the same graph. In our and other colleague
experience, the examination of such trend can be
predictive of the beginning of a prolonged air
leak (PAL). In every case the progressive
expansion can be appreciated especially in the
cases of compromise or emphysematous pulmonary
parenchyma.
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Utility of the available parameters by the
digital devices ?Superfluous complication or
real aid to the treatment of the patient ?

• As for other situations, it is not essential that
  the physician uses all and always the available
  performances. The use of the PALM EVO functions
  is extremely simplified and modular the
  physician can make trust on the parameters that
  will mostly hold profits in a particular moment
  or in another situation, without necessarily
  consulting the others. To example the simplest
  and useful parameter is, without doubt, the value
  of the hour-average air leak.
• The PALM EVO doesn't result to be intrusive,
  neither it has been planned for modifying the
  habits and the modus operands of the physician,
  on the contrary to suit itself for this.
• In a different context, the physician can
  progressively deepen the use of the instrument
  making trust on the other functionalities. In
  this view we can affirmed that the device is a
  real aid for the physician.

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Why to use a digital device?

• The adoption of a digital device in the
  management of the thoracic patient is of great
  utility since it furnishes certain elements and
  objective to analyze the p.o. period and to
  appraise the most opportune actions to undertake
  
• appraise the best moment for the removal of the
  drains
• avoiding further verifications, like the
  provocative clamping
• causes of more duration of the hospital stay
• best continuity results in the management of the
  patient (change turn of the physicians and the
  nurses)
• the physician has all the data that the device
  also picks up in his absence.
• Today also, the physician is founded on the news
  during the examination round ward or that he
  draws by the colleagues on the medical record. A
  digital device allows to have a continuous
  control improving the general monitoring of the
  patient.

oral narration
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Why to employ really the digital drain REDAX PALM
EVO ?

• All the advantages before illustrated are
  available in simple, sure and immediate way.
• The device facilitates the physician and nurse
  management to advantage of the safety of the
  patient (the touch screen facilitates the
  consultation from the physician but, being
  normally off, it doesn't influence the management
  from the nurses).
• The device allows a complete mobility of the
  patient for a fast recovery and relieving the
  load of job of the hospital personnel.
• The PALM EVO has unique and innovative
  characteristics that to today make it the
  available most complete system on the market.
• Finally, the cost of purchase and exercise is
  competitive in comparison to other devices.

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Thank you