Portable Ventilator Research Articles

A prospective, randomised trial of pre-oxygenation strategies available in the pre-hospital environment.

Pre-oxygenation before tracheal intubation aims to increase safe apnoea duration by denitrogenation of the functional residual capacity of the lungs, and increasing oxygen stores at the onset of apnoea. Pre-oxygenation options in the pre-hospital environment are limited due to oxygen availability and equipment portability. The aim of this study was to evaluate the effectiveness of strategies available in this setting. This was a prospective, randomised, crossover study of 30 healthy volunteers who underwent 3-min periods of pre-oxygenation by tidal volume breathing with a non-rebreather mask, a bag-valve-mask and a portable ventilator. The primary outcome measure was fractional expired oxygen concentration of the first exhaled breath after each technique. The secondary outcome measure was ease of breathing, assessed using a visual analogue scale. The mean (95%CI) fractional expired oxygen concentrations achieved with the non-rebreather mask were 64 (60-68)%, bag-valve-mask 89 (86-92)% and portable ventilator 95 (94-96)%. Pre-oxygenation efficacy with the non-rebreather mask was significantly worse than with either the bag-valve-mask (p < 0.001) or ventilator (p < 0.001). No significant difference in ease of breathing was identified between the bag-valve-mask and ventilator, but both were perceived as being significantly more difficult to breathe through than the non-rebreather mask. We conclude that, in healthy volunteers, the effectiveness of pre-oxygenation by bag-valve-mask and portable ventilator was superior to pre-oxygenation with a non-rebreather mask, although the non-rebreather mask was easier to breathe through than the other pre-oxygenation devices.

The Application of Biphasic Extrathoracic Cuirass-Assisted Ventilation in Normal Subjects Wearing Chemical-Biological-Radiological-Nuclear (CBRN) Gas Masks.

Mobile RTX (MRTX), a portable light-weighted ventilator, provides noninvasive respiratory support using biphasic extrathoracic cuirass-assisted ventilation. Despite the effectiveness of chemical-biological-radiological-nuclear (CBRN) gas masks, they cause respiratory loading as a result of added dead space and resistance. This prospective comparative pilot study was conducted to investigate the safety and efficacy of assisted ventilation provided by MRTX in healthy adult volunteers wearing CBRN gas masks at rest. Cardiorespiratory parameters were monitored in 11 healthy adult volunteers breathing spontaneously or with assisted ventilation provided by MRTX, freely or with the mask on. Comparisons were made by single-factor analysis of variance. AV significantly increased minute ventilation (p < 0.001). MRTX increased minute ventilation by 6.4 L/min (mean, 95% confidence interval: 3.1, 9.8; p < 0.005) and by 4.7 L/min (1.8, 7.5; p < 0.01) during spontaneous breathing and with the mask on, respectively. Simultaneously, end-tidal carbon dioxide partial pressure decreased by 3.6 mmHg (2.2, 5.1; p < 0.001) and by 6.5 mmHg (3.8, 9.1; p < 0.001). Biphasic extrathoracic cuirass assisted ventilation provided by MRTX is safe and effective in supporting adequate needs at rest even when wearing protective masks. MRTX should be further assessed as a possible adjunct to currently used field ventilation in CBRN scenarios.

Implementation of a respiratory rehabilitation protocol: weaning from the ventilator and tracheostomy in difficult-to-wean patients with spinal cord injury

Purpose: Following repeated weaning failures in acute care services, spinal cord injury (SCI) patients who require prolonged mechanical ventilation and tracheostomy are discharged to their homes or skilled nursing facilities, with a portable mechanical ventilator (MV) and/or tracheostomy tube (TT) with excess risk of complications, high cost and low quality of life. We hypothesized that many difficult-to-wean patients with cervical SCI can be successfully managed in a rehabilitation clinic. The aim of our study was to develop a respiratory rehabilitation, MV weaning and TT decannulation protocol and to evaluate the effectiveness of this protocol in tetraplegic patients.Methods: A multidisciplinary and multifaceted protocol, including respiratory assessment and management themes, was developed and performed based on the findings from other studies in the literature. Tetraplegic patients with the diagnosis of difficult-to-wean, who were admitted to the rehabilitation clinic after having been discharged from the intensive care unit to their home with home-type MV and/or TT, were included in this prospective observational study.Results: The respiratory rehabilitation protocol was applied to 35 tetraplegic patients (10 home-type MV and tracheostomy-dependent, and 25 tracheostomized patients) with C1-C7 ASIA impairment scale grade A, B, and C injuries. Seven out of 10 patients successfully weaned from MV and 30 of 35 patients were decannulated. Four patients were referred for diaphragm pace stimulation and tracheal stenosis surgery. The mean durations of MV weaning and decannulation were 37 and 31 days, respectively.Conclusions: A multifaceted, multidisciplinary respiratory management program can change the process of care used for difficult-to-wean patients with SCI.Implications for rehabilitationFindings from this study indicate the significance of a multidimensional evaluation of any reversible factors for prolonged MV- and/or TT-dependent SCI patients. Thus, rehabilitation specialists should take this into consideration and should provide the appropriate amount of time to these patients.The proposed protocol of respiratory rehabilitation for MV- and/or TT-dependent SCI patients shows promising results in terms of changing the care used for these patients.Successful implementation of a respiratory rehabilitation and weaning protocol is dependent on careful planning and detailed communication between the rehabilitation specialist and intensivist during the respiratory rehabilitation process.Because many of the so-called difficult- or impossible-to-wean patients were successfully weaned from MV and TT in the PMR clinic, the need for such an outlet for countries without specialized centers is supported.

Should a Portable Ventilator Be Used in All In-Hospital Transports?

Movement of the mechanically ventilated patient may be for a routine procedure or medical emergency. The risks of transport seem manageable, but the memory of a respiratory-related catastrophe still gives many practitioners pause. The risk/benefit ratio of transport must be assessed before movement. During transport of the ventilated patients, should we always use a transport ventilator? What is the risk of using manual ventilation? How are PEEP and FIO2 altered? Is there an impact on the ability to trigger during manual ventilation? Is hyperventilation and hypoventilation a common problem? Does hyperventilation or hypoventilation result in complications? Are portable ventilators worth the cost? What about the function of portable ventilators? Can these devices faithfully reproduce ICU ventilator function? The following pro and con discussion will attempt to address many of these issues by reviewing the current evidence on transport ventilation.

Performance of Portable Ventilators Following Storage at Temperature Extremes

In the current theater of operation, medical devices are often shipped and stored at ambient conditions. The effect of storage at hot and cold temperature extremes on ventilator performance is unknown. We evaluated three portable ventilators currently in use or being evaluated for use by the Department of Defense (731, Impact Instrumentation; T1, Hamilton Medical; and Revel, CareFusion) at temperature extremes in a laboratory setting. The ventilators were stored at temperatures of 60°C and -35°C for 24 hours and were allowed to acclimate to room temperature for 30 minutes before evaluation. The T1 required an extra 15 to 30 minutes of acclimation to room temperature before the ventilator would deliver breaths. All delivered tidal volumes at room temperature and after storage at temperature extremes were less than the ±10% American Society for Testing and Materials standard with the Revel. Delivered tidal volumes at the pediatric settings were less than the ±10% threshold after storage at both temperatures and at room temperature with the 731. Storage at extreme temperature affected the performance of the portable ventilators tested. This study showed that portable ventilators may need an hour or more of acclimation time at room temperature after storage at temperature extremes to operate as intended.

Ventilator-assisted preoxygenation: Protocol for combining non-invasive ventilation and apnoeic oxygenation using a portable ventilator.

To describe a simple protocol for ventilator-assisted preoxygenation (VAPOX) prior to rapid sequence intubation in the ED using a Hamilton T1 ventilator in an effort to further reduce the incidence of transient and critical hypoxaemia. Ventilator-assisted preoxygenation includes the following steps; preparation for rapid sequence intubation as per institutional protocols, including departmental checklists. Hamilton T1 ventilator is setup in non-invasive spontaneous/timed mode with settings as described. The patient is optimally positioned and nasal cannula applied with an oxygen flow rate of 15 L/min. A face mask is applied with the jaw pulled forward using a two-handed thenar eminence grip and the ventilator is started. Preoxygenation occurs for 3 min. Drugs including neuromuscular blockers are administered, while the operator ensures the airway remains patent. The ventilator transitions into Pressure Controlled Ventilation once apnoea ensues. Nasal oxygen continues until endotracheal tube is successfully secured. We describe a case series of the first eight consecutive adult patients on who VAPOX was applied. All eight patients were clinically deemed at high risk of oxygen desaturation. No clinically significant hypoxia occurred, and the lowest oxyhaemoglobin desaturation was 92%. Preoxygenation using a ventilator with an open valve system may allow safe combination of non-invasive ventilation, pressure controlled ventilation and apnoeic oxygenation using nasal cannula. VAPOX may be the technique of choice to preoxygenate and apnoeic oxygenate many patients who undergo rapid sequence intubation in the ED equipped with these ventilators.

Home monitoring of daytime mouthpiece ventilation effectiveness in patients with neuromuscular disease.

Mouthpiece ventilation (MPV) allows patients with neuromuscular disease to receive daytime support from a portable ventilator, which they can disconnect at will, for example, for speaking, eating, swallowing, and coughing. However, MPV carries a risk of underventilation. Our purpose here was to evaluate the effectiveness of daytime MPV under real-life conditions. Eight wheelchair-bound patients who used MPV underwent daytime polygraphy at home with recordings of airflow, mouthpiece pressure, thoracic and abdominal movements, peripheral capillary oxygen saturation (SpO2), and transcutaneous partial pressure of carbon dioxide (PtcCO2). Times and durations of tasks and activities were recorded. The Apnea-Hypopnea Index (AHI) was computed. Patient-ventilator disconnections ≥3 minutes and episodes of hypoventilation defined as PtcCO2>45 mmHg were counted. Patient-ventilator asynchrony events were analyzed. The AHI was >5 hour(-1) in two patients. Another patient experienced unexplained 3% drops in arterial oxygen saturations at a frequency of 70 hour(-1). Patient-ventilator disconnections ≥3 minutes occurred in seven of eight patients and were consistently associated with decreases in SpO2 and ≥5-mmHg increases in PtcCO2; PtcCO2 rose above 45 mmHg in two patients during these disconnections. The most common type of patient-ventilator asynchrony was ineffective effort. This study confirms that MPV can be effective as long as the patient remains connected to the mouthpiece. However, transient arterial oxygen desaturation and hypercapnia due to disconnection from the ventilator may occur, without inducing unpleasant sensations in the patients. Therefore, an external warning system based on a minimal acceptable value of minute ventilation would probably be useful.

A 10.4 mW Electrical Impedance Tomography SoC for Portable Real-Time Lung Ventilation Monitoring System

An electrical impedance tomography (EIT) SoC is proposed for the portable real-time lung ventilation monitoring system. The proposed EIT SoC is integrated into belt-typefabric system with 32 electrodes and can show the dynamic images of the lung ventilation on the mobile devices. To get high fidelity images, a T-switch is adopted for high off-isolation between electrodes more than 60 dB, and I/Q signal generation and demodulation can obtain both real and imaginary part of images. For the real-time imaging, an on-chip fast demodulation scheme is proposed, and it can also reduce speed requirements of ADC for low-power consumption. The proposed EIT SoC of 5.0 mm × 5.0 mm is fabricated in 0.18 µm CMOS technology, and consumes only 10.4 mW with 1.8 V supply. As a result, EIT images were reconstructed with 97.3% of accuracy and up to 20 frames/s real-time lung images can be displayed on the mobile devices.

Health Care Utilization and Respiratory Health Status in Patients With Chronic Respiratory Insufficiency Following Addition of a Portable Noninvasive Ventilator to the Treatment Regimen

Health Care Utilization and Respiratory Health Status in Patients With Chronic Respiratory Insufficiency Following Addition of a Portable Noninvasive Ventilator to the Treatment Regimen

Evaluation of a Novel Highly Portable Nasal Noninvasive Ventilator in Patients With Chronic Respiratory Disease During Constant Work Rate (CWR) Exercise

Evaluation of a Novel Highly Portable Nasal Noninvasive Ventilator in Patients With Chronic Respiratory Disease During Constant Work Rate (CWR) Exercise

Evacuation of Intensive Care Units During Disaster: Learning From the Hurricane Sandy Experience.

Data on best practices for evacuating an intensive care unit (ICU) during a disaster are limited. The impact of Hurricane Sandy on New York City area hospitals provided a unique opportunity to learn from the experience of ICU providers about their preparedness, perspective, roles, and activities. We conducted a cross-sectional survey of nurses, respiratory therapists, and physicians who played direct roles during the Hurricane Sandy ICU evacuations. Sixty-eight health care professionals from 4 evacuating hospitals completed surveys (35% ICU nurses, 21% respiratory therapists, 25% physicians-in-training, and 13% attending physicians). Only 21% had participated in an ICU evacuation drill in the past 2 years and 28% had prior training or real-life experience. Processes were inconsistent for patient prioritization, tracking, transport medications, and transport care. Respondents identified communication (43%) as the key barrier to effective evacuation. The equipment considered most helpful included flashlights (24%), transport sleds (21%), and oxygen tanks and respiratory therapy supplies (19%). An evacuation wish list included walkie-talkies/phones (26%), lighting/electricity (18%), flashlights (10%), and portable ventilators and suction (16%). ICU providers who evacuated critically ill patients during Hurricane Sandy had little prior knowledge of evacuation processes or vertical evacuation experience. The weakest links in the patient evacuation process were communication and the availability of practical tools. Incorporating ICU providers into hospital evacuation planning and training, developing standard evacuation communication processes and tools, and collecting a uniform dataset among all evacuating hospitals could better inform critical care evacuation in the future.

2. Challenge of organ shortage is enormous, but we’re heading towards a future where we have time and ability to improve and augment organs before more and better transplants

Over the past four decades, Lung transplant has evolved to a successful modality for treating end stage lung disease in selected patients. However, lung transplant is not problem-free. Primary graft dysfunction is the most severe form of post transplant lung ischemia and reperfusion injury and is correlated with early and late mortality after lung transplantation. Many studies have been performed to optimize the donor lung preservation in order to minimize ischemic injury to the donor lung. However, no major breakthrough has been made in donor lung preservation. Cold flush and storage has been accepted as a standard preservation of donor lungs in clinical lung transplantation. With the concept of living organ transplant, that is, heart beating, lung breathing, kidney making urine and liver producing bile, Transmedics developed a portable ex-vivo warm perfusion system that allows the donor lungs functioning and “breathing” in a near-physiologic state outside the body during transport, thus minimizing the donor lung ischemic time. Gregor Warnecke and his colleagues reported first-in-man experience of the portable OCS lung device for concomitant preservation, assessment and transport of donor lungs. It demonstrated that lungs can be safely preserved with the OCS lung, resulting in complete organ use and successful transplantation in their high-risk recipients. As one of the major lung transplant centers participating in the INSPIRE trial, the lung transplant team at Ronald Reagan UCLA medical center successfully performed the nation’s first “breathing lung” transplant in November, 2012. The INSPIRE trial has been conducted in leading lung transplant centers in Europe, the United States, Australia, and Canada. The interim results from the INSPIRE trial are suggesting significant improvement in post lung transplant clinical outcomes using the TransMedics OCS lung portable perfusion and ventilation system. In addition, other important clinical parameters such as in-hospital mortality, 6-month survival, rate of lung-related complications, time on mechanical ventilation and ICU stay may be better in the OCS group as compared to cold storage. With OCS, surgeons may accept suboptimal organs or those obtained from non-heart-beating donors through assessment of donor lung function at donor site, thus expending the donor pool without compromising patient outcome. The OCS lung enables surgeons to continuously monitor and assess the lung function and quality until transplantation. By doing so, it makes the recipient transplant team coordinate with the procure team easier, the timing of recipient incision more flexible. It allows two separate single lung transplantation that share lungs from one donor proceeding one after the other. OCS lung also allows surgeons to procure lungs over longer distance, leading to development of an international organ sharing system. We believe that this OCS lung technology has a potential of bringing human lung transplantation to a new cornerstone.

Portable mechanical ventilation with closed-loop control of inspired fraction of oxygen maintains oxygenation in the setting of hemorrhage and lung injury.

Closed-loop controllers (CLCs) embedded within portable mechanical ventilators may allow for autonomous weaning. The ability of CLCs to maintain adequate oxygenation in the setting of hemorrhage and lung injury is unknown. We hypothesized that a portable ventilator with a CLC for inspired fraction of oxygen (FIO2) could provide oxygenation in a porcine model of hemorrhage and lung injury. Female pigs randomized to the study group (n = 6) underwent a pressure-controlled bleed (mean arterial pressure = 40 mm Hg for 30 minutes). Acute lung injury was induced by saline lung lavage followed by intentional infliction of barotrauma. Sham pigs (n = 6) underwent placement of monitoring devices without hemorrhage or lung injury. All pigs were then placed on a portable ventilator modified with a CLC algorithm, which uses feedback from pulse oximetry (SpO2) and FIO2 trends to adjust FIO2 and maintain a target SpO2 of 94% (2%). The initial FIO2 was set at 0.60. Tidal volume, positive end-expiratory pressure, rate, and inspiratory-to-expiratory ratio were constant unless changes were required clinically. Study pigs had lower mean arterial pressures than shams at all time points except baseline. PaO2/FIO2 ratios were less than 300 and significantly lower than both baseline values and corresponding sham values at all time points. The CLC weaned the FIO2 at a reduced rate in study pigs relative to shams with a final mean FIO2 of 0.54 and 0.29 in study and sham pigs, respectively (p < 0.05). There was a significant divergence in the study and sham FIO2 curves but no significant difference in oxygen saturation or hypoxemia. Adequate oxygenation can be maintained in the setting of hemorrhage and lung injury using a portable ventilator embedded with a CLC of FIO2 based on pulse oximetry. These devices may be valuable for providing advanced medical care in resource-limited environments.

Diaphragm Pacing without Tracheostomy in Congenital Central Hypoventilation Syndrome Patients

Background: Congenital central hypoventilation syndrome (CCHS) is a rare disorder affecting central control of breathing. Thus, patients require lifelong assisted ventilation. Diaphragm pacing (DP) may permit decannulation in those who are ventilator dependent only during sleep. Objective: The purpose of this study is to determine if patients with CCHS can be successfully ventilated by DP without tracheostomy. Methods: We reviewed the records of 18 CCHS patients (mean age 19.5 ± 10.1 years; 44% female) who were ventilated by DP only during sleep. Results: Prior to diaphragm pacer implantation surgery, 14 CCHS patients had been using home portable positive pressure ventilation (PPV) via tracheostomy, 1 had been on PPV via endotracheal tube, and 3 had been using noninvasive PPV (NPPV). Of the patients with tracheostomy prior to DP (n = 15), 11 (73%) were decannulated and ventilated successfully by DP without tracheostomy. Of all the patients reviewed (n = 18), 13 (72%) were successfully ventilated by DP without tracheostomy. Obesity prevented successful DP without tracheostomy in 1 patient, and upper airway obstruction prevented success in another patient. Snoring and/or obstructive apneas were present in some patients, but they were improved by diaphragm pacer changes, adenotonsillectomy, and/or use of nasal steroids. Conclusions: DP without tracheostomy can be successfully achieved in patients with CCHS. Snoring and obstructive apneas, when present, can be managed by diaphragm pacer changes and medical therapies. Obesity can pose a challenge to successful DP.

How to enhance experience and skill of non invasive ventilation: suggestions from the literature

19 have seen an iron lung, yet sixty years ago these medical mechanical monsters would have been a common sight in most hospital throughout the world. Through the late 1920’s and into 50’s the iron lung was considered to be state of the art, high-tech, life support technology. Indeed medical physician of the time would have learn about such devices as a recommended treatment for respiratory paralysis, used to maintain life for those whose breathing capabilities had been impaired or destroyed by poliomyelit is (1).They were non invasive in the sense that no part of the device penetrated the patient. In truth, it was the patient who was inside the machine. The whole body was enclosed within the air tight chamber of the device, apart from the head which protruded through a tight seal around the neck (Figure 1). For each inspiration a large set of leather bellows mounted in a separate pump unit would expand causing the pressure within the cabinet to be lowered to below that of the surrounding atmosphere. The sub-atmospheric pressure in turn acted upon the chest, causing it to expand, thereby drawing fresh air into the lungs through the patients’ mouth. During expiration, the pressure equalise to atmospheric and the patient exhals passively. This method of artificial respiration was known as external negative pressure ventilation (ENPV). The first description of ventilator support via mouthpiece was described by Dr.Affeldt of Rancho Los Amigos in 1953 (Figure 2), to assist patients when the iron lung was open for patient care (1, 2). He observed that intermittent positive pressure administered by a circuit with a mouthpiece could be used to relieve dyspnea in patients with polio ventilator-dependence when negative pressure ventilation had been interrupted for transfers, nursing or physical therapy (1, 2). However, intermittent positive pressure breathing (IPPB) machine became available even earlier than 1951 and a positive pressure blower caller was used to deliver occasional deep breaths as well. Patients used mouthpiece NIV in a wheelchair as well as use an intermittent abdominal pressure ventilator (IAPV) or other portable negative pressure ventilators. Since IPPV via mouthpiece Bantam became available and since the IPPV via mouthpiece was able to provides much larger volumes of air directly to the lungs than the IAPV, it became the principal mode of ventilatory support during lung infections and other conditions of lung impairment. The mouthpieces were mounted on the controls of powered Mini-review

Performance of ventilators compatible with magnetic resonance imaging: a bench study.

Magnetic resonance imaging (MRI) is indispensable for diagnosing brain and spinal cord abnormalities. Magnetic components cannot be used during MRI procedures; therefore, patient support equipment must use MRI-compatible materials. However, little is known of the performance of MRI-compatible ventilators. At commonly used settings, we tested the delivered tidal volume (V(T)), F(IO2), PEEP, and operation of the high-inspiratory-pressure-relief valves of 4 portable MRI-compatible ventilators (Pneupac VR1, ParaPAC 200DMRI, CAREvent MRI, iVent201) and one ICU ventilator (Servo-i). Each ventilator was set in volume control/continuous mandatory ventilation mode. Breathing frequency and V(T) were tested at 10 breaths/min and 300, 500, and 700 mL, respectively. The Pneupac VR1 has fixed V(T) and frequency combinations, so it was tested at V(T) = 300 mL and 20 breaths/min, V(T) = 500 mL and 12 breaths/min, and V(T) = 800 mL and 10 breaths/min. F(IO2) was 0.6 and 1.0. At the air-mix setting, F(IO2) was fixed at 0.5 with the Pneupac VR1, 0.45 with the ParaPAC 200DMRI, and 0.6 with the CAREvent MRI. PEEP was set at 5 and 10 cm H2O, and pressure relief was set at 30 and 40 cm H2O. V(T) error varied widely among ventilators (-28.1 to 25.5%). As V(T) increased, error decreased with the Pneupac VR1, ParaPAC 200DMRI, and CAREvent MRI (P < .05). F(IO2) error ranged from -13.3 to 25.3% at 0.6 (or air mix). PEEP error varied among ventilators (-29.2 to 42.5%). Only the Servo-i maintained V(T), F(IO2), and PEEP at set levels. The pressure-relief valves worked in all ventilators. None of the MRI-compatible ventilators maintained V(T), F(IO2), and PEEP at set levels. Vital signs of patients with unstable respiratory mechanics should be monitored during transport and MRI.

Board #135 - Research Abstract Interim Results of Randomized Controlled Simulation Testing of Standard and Automated Device-Assisted Pre-hospital Cardiac Arrest Resuscitation Approaches (Submission #8205)

Hypothesis Automation of labor-intensive, repetitive and critical sudden cardiac arrest (SCA) resuscitation tasks will result in improved resuscitation quality. Automated device-assisted SCA protocols and equipment will de-emphasize the hierarchical BLS-ALS classification of SCA resuscitation activities without adversely impacting resuscitation quality. A comprehensive, high-resolution simulation assessment methodology with meaningful objective metrics can be used to realistically and progressively assess standard and experimental approaches to prehospital SCA resuscitation. LUCAS2 chest compressor, automated external defibrillation (AED) guidance, supraglottic airway (SGA or ILMA), portable mechanical ventilator, EZ-IO access device, limited selection of SCA medication. Methods EMS teams (each comprising one EMT-B and one ALS provider) were randomized to control group or experimental group. Each team engaged in 3 SCA simulations: 1) baseline scenario in standard roles; 2) repeat scenario in standard roles; and 3) repeat scenario in reversed roles, for example, BLS provider performing ALS tasks. Control teams operated with standard state protocols and equipment only (with 30-min sham intervention on high-performance CPR); experimental teams used resuscitation-automating devices and accompanying goal-directed algorithmic resuscitation protocol for scenarios 2 and 3 (with 30-min in-servicing). Audiovisual records, simulator logs and PC screencaptures collected data on chest compression, defibrillation, airway management, ventilation, vascular access, medications and transport. Team performance data were extracted and scored on each dimension relative to the best and worst performances for each scenario, with ACLS guidelines used as the gold standard when possible. Results Five control teams and five experimental teams of an anticipated 20-team sample have completed the study (10 EMT-Bs, 6 EMT-Cs, 4 EMT-Ps; mean age 30 years [range 21-52], mean 6 years at primary practice [2-21]; mean 20 SCA patient experience [0-200]). Baseline performance of chest compression and defibrillation was poor in both groups. Control teams performed similarly across scenarios 1 and 2 despite high-performance CPR didactic and skills stations. Experimental teams’ resuscitations improved in most areas, i.e., compression (mean depth: 41% of best performance scenario 1; 91% scenario 2), proportion of adequate compressions (11%; 61%), airway management (40%; 80%), ventilation (22%; 79%), vascular access (20%; 100%) and medication administration (20%; 100%). These improvements persisted in experimental groups when provider roles were reversed for the third scenario; control groups with standard protocols and reversed roles exhibited reduced resuscitation quality in all areas. Conclusion Automated assistance of critical, time- and resource-intensive SCA resuscitation tasks by electromechanical adjuncts improved the in-simulation performance of 2-provider EMS teams on nearly all resuscitation parameters studied. These improvements were maintained in experimental teams even with reversal of BLS and ALS provider roles. Although there are costs and risks to implementing resuscitation-automating protocols and equipment, the early suggestion of a strong trend towards improved clinical management hints at the potential real-world value of this approach. The simulation assessment methodology employed by the ongoing study has facilitated the analysis and innovative representation of prehospital clinical practice performance and will be applied to continuing and future studies. Disclosures Leo Kobayashi receives grant support from the University Emergency Medicine Foundation and Lifespan. Nicolas Asselin’s spouse receives salary support and owns stock in Biogen, Idec of Cambridge Massachusetts.

Impact of duration of Prolong Manual Bag ventilated patients in the Emergency Service

Introduction: There are increasing numbers of critically ill patients who need urgent emergency intubation in Emergency Service. Due to limited number of ventilators and even lack of portable ventilators in emergency room, we need to continue prolong manual bag ventilation of those patients after emergency intubation. Therefore, the aim was to analyse the impact of duration of prolong manual bag ventilated patients in the Emergency Service, Tribhuvan University Teaching Hospital in Nepal. Methods: This was a prospective non-interventional cross-sectional study conducted from August 2012 to July 2013 (one year). This study included those Emergency Intubation cases with written informed consent from patient's party/guardian/legal representative to enroll in this study and excluding otherwise. Results: 172 (0.4% of 45000 emergency room patients) patients were enrolled and divided in to Group I: Manual Bag Ventilation without Mechanical Ventilation (MBV-MV)-56 (32.6%) and Group II. MBV with MV (MBV+MV) 116 (67.4%) with accounting the incidence of such critically ill rarely found cases. The age ranges from 11 to 94 years with mean 49+-19. There were 33 Alive and 139 Death (p 0.006), M:F=1.32:1, MBV duration was with median 540 min (p0.02), 22.7% had &lt;180 minutes MBV with survival rate 28.25% (OR 1.98, p 0.162 comparing with &gt;181 minutes), 58.2% cases were only MBV in ER with 100% mortality. 41.2% had mechanical ventilation after MBV with median 3 days, mean 5.0+-SD 4.9 days in ICUs with 71.5% crude ill-defined mortality (p 0.042, ROC0.704). The probability of survival after emergency intubation varies with duration of MIBV as 0.8 in 1hr (7.1% mortality) and 0.02 after 24hrs (92.3% mortality) with underlying causes and availability of present treatment. Conclusion: Irrespective of underlying causes, due to prolong manual bag ventilation without mechanical ventilation; there was increase chance of mortality and even 100% mortality as ill-defined crude mortality.

Open circuit mouthpiece ventilation: Concise clinical review

In 2013 new “mouthpiece ventilation” modes are being introduced to commercially available portable ventilators. Despite this, there is little knowledge of how to use noninvasive intermittent positive pressure ventilation (NIV) as opposed to bi-level positive airway pressure (PAP) and both have almost exclusively been reported to have been used via nasal or oro-nasal interfaces rather than via a simple mouthpiece.Non-invasive ventilation is often reported as failing because of airway secretion encumbrance, because of hypercapnia due to inadequate bi-level PAP settings, or poor interface tolerance. The latter can be caused by factors such as excessive pressure on the face from poor fit, excessive oral air leak, anxiety, claustrophobia, and patient-ventilator dys-synchrony. Thus, the interface plays a crucial role in tolerance and effectiveness. Interfaces that cover the nose and/or nose and mouth (oro-nasal) are the most commonly used but are more likely to cause skin breakdown and claustrophobia. Most associated drawbacks can be avoided by using mouthpiece NIV. Open-circuit mouthpiece NIV is being used by large populations in some centers for daytime ventilatory support and complements nocturnal NIV via “mask” interfaces for nocturnal ventilatory support. Mouthpiece NIV is also being used for sleep with the mouthpiece fixed in place by a lip-covering flange. Small 15 and 22mm angled mouthpieces and straw-type mouthpieces are the most commonly used.NIV via mouthpiece is being used as an effective alternative to ventilatory support via tracheostomy tube (TMV) and is associated with a reduced risk of pneumonias and other respiratory complications. Its use facilitates “air-stacking” to improve cough, speech, and pulmonary compliance, all of which better maintain quality of life for patients with neuromuscular diseases (NMDs) than the invasive alternatives. Considering these benefits and the new availability of mouthpiece ventilator modes, wider knowledge of this technique is now warranted. This review highlights the indications, techniques, advantages and disadvantages of mouthpiece NIV.

FiO2 Delivered By a Turbine Portable Ventilator with an Oxygen Concentrator in an Austere Environment

BackgroundManagement of critically ill patients in austere environments is a logistic challenge. Availability of oxygen cylinders for the mechanically ventilated patient may be difficult in such a context. A solution is to use a ventilator able to function with an oxygen concentrator. ObjectivesWe tested the SeQual Integra™ (SeQual, San Diego, CA) 10-OM oxygen concentrator paired with the Pulmonetic System® LTV 1000 ventilator (Pulmonetic Systems, Minneapolis, MN) and evaluated the delivered fraction of inspired oxygen (FiO2) across a range of minute volumes and combinations of ventilator settings. MethodsTwo LTV 1000 ventilators were tested. The ventilators were attached to a test lung and FiO2 was measured by a gas analyzer. Continuous-flow oxygen was generated by the OC from 0.5 L/min to 10 L/min and injected into the oxygen inlet port of the LTV 1000. Several combinations of ventilator settings were evaluated to determine the factors affecting the delivered FiO2. ResultsThe LTV 1000 ventilator is a turbine ventilator that is able to deliver high FiO2 when functioning with an oxygen concentrator. However, modifications of the ventilator settings such as increase in minute ventilation affect delivered FiO2 even if oxygen flow is constant on the oxygen concentrator. ConclusionsThe ability of an oxygen concentrator to deliver high FiO2 when used with a turbine ventilator makes this method of oxygen delivery a viable alternative to cylinders in austere environments when used with a turbine ventilator. However, FiO2 has to be monitored continuously because delivered FiO2 decreases when minute ventilation is increased.