Welcome HillRom presents HFCWO airway clearance therapy Hospital to Home

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Welcome Hill-Rom presents HFCWO airway
clearance therapy Hospital to Home
Presented by Mark Nystrom, RRT National Sales
Trainer, Hill-Rom. Sponsored by Hillenbrand Ind.
Inc.
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11 Million pulmonary patients hospitalized each
year 1.5 Million requiring Airway Clearance
Therapy

• HFCWO for airway clearance has been prescribed
  for more than 62,000 patients

Source Solucient Hospital discharge data 2002
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Rationale for Identifying High Risk Patients
Major Pulmonary Complications

• Atelectasis
• Pneumonia
• Infection
• Respiratory Failure
• Failure to Wean
• Atelectasis and infections are the most
  frequently reported

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Cycle of Respiratory Impairment
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Applications/Factors that Affect Airway Clearance

• Poor, ineffective or absent cough
• Pain
• Decreased muscle function
• Diaphragm impairment
• Decreased ventilation/lung volumes
• Impaired gas exchange
• Alveolar impairment
• Absence of periodic deep breaths/sighs
• Inadequate airflows

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Applications/Factors that Affect Airway Clearance
continued

• Decreased respiratory drive
• Sedation
• Medications
• Neuro injuries
• Impaired mucociliary clearance
• Artificial airways/mechanical ventilation
• Hypersecretions
• Immobility
• Abnormal mucous flow

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Identifying High Risk PatientsPatient Related
Risks

• General health/age
• Chronic/systemic disease
• Co morbidities
• COPD
• Recent respiratory infection
• Smoking history
• Obesity/malnutrition
• Trauma
• High level SCI or head injury
• Immobility

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Identifying High Risk PatientsProcedure
Related Risks

• Duration of surgery
• Type of anesthesia
• Impairment of respiratory muscle function
• Alterations in lung volumes in supine position
• Surgical site
• Thoracic resections
• Coronary bypass grafting
• Upper abdominal surgeries
• Surgery for trauma
• Head and neck procedures
• Some orthopedic procedures

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Chest Physical Therapy, (CPT)The Old Gold
Standard

• 12 positions
• Uses gravity
• Percussion/vibration
• Time consuming
• Labor intensive
• Poorly tolerated by most patients
• Reflux and GERD

Postural drainage positions
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Head Down vs. Heads UpButton et al 5 year study
20 asymptomatic infants

• Head down group
• Significantly more days of URIs
• Longer course of antibiotics at 1 year
• Worse CXR scores at 2.5 years
• Worse PFTs at 5 years

Button Et. Al Journal of Paeditrics Child Health
(1998) 34, 330-334 "Postural drainage in cystic
fibrosis Is there a link with gastro-esophageal
reflux?"
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Research King Study (Montreal, 1983)

• Frequencies of 3-17 Hz
• with piston pump/bladder
• Oscillated volumes 25-100cc
• Flow rate 1-3L/sec
• 340 increase in mucus
• clearance rate

King M, Phillips D, Gross D, Vartian V, Chang HK,
Zidulka A. Enhanced tracheal mucus clearance
with high frequency chest wall compression. Am
Rev Respir Dis 1983128511-515.
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HFCWO History

• Originally developed for Cystic Fibrosis patients
  at home
• Over 65 of CF patients in the US are using The
  Vest
• Studies in CF showed
• Safety
• Cost savings
• Efficacy
• Acceptance by HCT and Patients
• Improved PFTs
• Increased sputum production
• Patient need drove Vest into other disease states
  and hospital use

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HFCWO The Vest Airway Clearance System

• Inflatable vests connected by hoses to air-pulse
  generator, rapidly inflates and deflates
  producing high-frequency chest wall oscillation
  (HFCWO)

Model 105 - home
Model 205 - hospital
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Mechanism of Action
Flow Rate During Oscillation Cycle
The Vest system produces cough-like shear forces.
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Benefits of HFCWO

• Decreased morbidity/mortality(1)
• Enhanced quality of life
• Treats all lobes simultaneously
• Save treatment time
• Cost savings(2)
• Promotes compliance through
• Reduced effort
• Technique/patient independence
• No positioning

(1) Nuke IM, Shapiro S, et al. Comparison of
HFCWO and CPT in ventilator dependent patients.
Chest 1999 (2) Onsorg f.. Cost comparison of
HFCWO in CF. Adv Mgrs Respir Care 1994
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Research

• Study Locations

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Research Warwick Study (University of
Minnesota, 1991)

• 2 years pre/post HFCWO
• Measured trends in
• predicted FVC FEV1

Warwick W. High-frequency chest compression moves
mucus by means of sustained staccato coughs.
Pediatr Pulmonol 1991 Suppl 6 283 A219.  
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Research
Ohnsorg Study (Minnesota BCBS, 1994)
Cost Value Analysis

• 23 CF patients
• 49 reduction in healthcare expenditures

Ohnsorg F. A cost analysis of
high-frequency chest wall oscillation in cystic
fibrosis Am J Respir Crit Care Med 1994 149(4pt.
2)A669
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Reimbursementfor The Vest

• Private insurances
• Medicaid
• VA Federal Supply Schedule
• Medicare
• - coverage for CF and Bronchiectasis with CT
• - other diagnoses
• Payment Options

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Top Non-CF Diagnoses for use of HFCWO in Home
Care

• Bronchiectasis
• Cerebral Palsy
• Immotile Cilia Syndrome
• Spinal Cord Injury
• Muscular Dystrophy
• Spinal Muscular Atrophy
• 87 of home referrals are non-CF

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Research Brierley, et al. (Phoenix, AZ and
Salina, KS)

• Assess safety and tolerance in acutely ill
  hospitalized
• patients in presence of multiple therapeutic
  interventions
• 73 patients received HFCWO therapy typically
  was 15 minutes 2-3 times per day
• Typically initiated with 24-72 hours post op
• Multiple equipment/therapy did not effect
  delivery of HFCWO (i.e. chest tubes, Swan Ganz
  catheter, external pacing wires, mechanical
  ventilation)
• HFCWO via The Vest system safe and well-tolerated
  airway clearance therapy for many post surgical
  and critical care patients

Brierly S, Adams C, Suelter J, Grooch T, Becker
B. Safety and tolerance of high- frequency chest
wall oscillation (HFCWO) in hospitalized
critical care patients. Arizona Heart
Hospital, Phoenix AZ, Salina Regional Health
Center, Salina KS, Advanced Respiratory Inc.,
Saint Paul, MN.
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Research Allan, et al. (Boston, MA 2003)

• Post operative management of post thoracic
  surgical
• patients using HFCWO
• 25 patients received HFCWO _at_ 12 Hz for 10 minutes
  each treatment
• No adverse events reported
• 84 of patients had little or no discomfort
  during therapy
• HFCWO was preferred to CPT, 21
• HFCWO safe and well tolerated for routing post op
  treatment of elective thoracic procedures

Allan, JS, Garrity JM, Donahue, DM. The Utility
of High-Frequency Chest Wall Oscillation Therapy
in the Post-Operative Management of Thoracic
Surgical Patients. Abstract Control/Tracking
Number 03-A-732-ACCP
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Summary of Research Supports

• Increased sputum mobilization
• Improved pulmonary function
• Cost effectiveness
• Decreased hospitalizations, ICU days
• Decreased antibiotic/oxygen needs
• Safety / efficacy in multiple disease states
• Safety in ICU/post cardiac surgery
• Improved weaning from vents
• Combining with other airway clearance therapies
• Supporting study in this presentation (King,
  Warwick, Landon, Plypolis, Allen, Brierley)

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Safety and Effectiveness

• Can be used with mechanical ventilation
• Aerosols can be delivered during treatment
• Doesnt require patient effort or cooperation
• No positioning required
• Treats all lobes at the same time

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Contraindications
Absolute contraindications for airway clearance
therapy

• Head and/or neck injury which has not yet been
  stabilized
• Active hemorrhage with hemodynamic
• instability
• Adapted from the AARC Clinical Practice
  Guidelines for the External Manipulation of the
  Thorax

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Relative Contraindications/Considerations

• Pulmonary hemorrhage
• Hypoxia
• Increased intracranial pressure
• Vomiting and aspiration
• Acute hypotension during the procedure
• Pain or injury to muscles, ribs or spine
• Dysrhythmias
• Adapted from the AARC Clinical Practice
  Guidelines for the External Manipulation of the
  Thorax (CPT),
• For a complete list see published guidelines.

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Conclusions

• Summary of HFCWO
• Safe and effective in numerous diseases/conditions
  
• Produces transient increases in airflow/mini
  coughs
• Mobilizes and changes physical properties of
  secretions
• Provides consistent, quality therapy at home
• Technique independent/easy to use
• HFCWO helps everyone to breathe a little easier!

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Vest Demonstration