Resuscitation Bag Research Articles

Use of air stacking and abdominal compression for cough assistance in people with complete tetraplegia

Cross-sectional. To assess cough using air stacking (AS) to assist inspiratory volume with abdominal compression (AC) during expiration in patients with American Spinal Injury Association Impairment Scale (AIS) A. Large tertiary hospital in Chile. Peak cough flow (PCF) was measured during four different interventions: spontaneous maximal expiratory effort (MEE); MEE while receiving AC (MEE-AC); MEE after AS with a manual resuscitation bag (AS-MEE); and MEE with AS and AC (AS-MEE-AC). Fifteen in-patients with complete tetraplegia (C4-C6) were included. Median age was 33 years (16-56). PCF during the different interventions was PCF for MEE was 183±90 l min(-1); PCF for MEE-AC was 273±119 l min(-1); PCF for AS-MEE was 278±106 l min(-1) and PCF for AS-MEE-AC was 368±129 l min(-1). We observed significant differences in PCF while applying MEE-AC and AS-MEE compared with MEE (P=0.0001). However, the difference in PCF value was greater using the AS-MEE-AC technique (P=0.00001). Patients with spinal cord injury (SCI) presented an ineffective cough that constitutes a risk factor for developing respiratory complications. The application of combined techniques (AS-MEE-AC) can reach near normal PCF values. This is a low-cost, simple and easily applied intervention that could be introduced to all patients with tetraplegia.

Assessment of essential newborn care services in secondary-level facilities from two districts of India.

India faces a formidable burden of neonatal deaths, and quality newborn care is essential for reducing the high neonatal mortality rate. We examined newborn care services, with a focus on essential newborn care (ENC) in two districts, one each from two states in India. Nagaur district in Rajasthan and Chhatarpur district in Madhya Pradesh were included. Six secondary-level facilities from the districts-two district hospitals (DHs) and four community health centres (CHCs) were evaluated, where maximum institutional births within districts were taking place. The assessment included record review, facility observation, and competency assessment of service providers, using structured checklists and sets of questionnaire. The domains assessed for competency were: resuscitation, provision of warmth, breastfeeding, kangaroo mother care, and infection prevention. Our assessments showed that no inpatient care was being rendered at the CHCs while, at DHs, neonates with sepsis, asphyxia, and prematurity/low birthweight were managed. Newborn care corners existed within or adjacent to the labour room in all the facilities and were largely unutilized spaces in most of the facilities. Resuscitation bags and masks were available in four out of six facilities, with a predominant lack of masks of both sizes. Two CHCs in Chhatarpur did not have suction device. The average knowledge score amongst service providers in resuscitation was 76% and, in the remaining ENC domains, was 78%. The corresponding average skill scores were 24% and 34%, highlighting a huge contrast in knowledge and skill scores. This disparity was observed for all levels of providers assessed. While knowledge domain scores were largely satisfactory (> 75%) for the majority of providers in domains of kangaroo mother care and breastfeeding, the scores were only moderately satisfactory (50-75%) for all other knowledge domains. The skill scores for all domains were predominantly non-satisfactory (< 50%). The findings underpin the need for improving the existing ENC services by making newborn care comers functional and enhancing skills of service providers to reduce neonatal mortality rate in India.

Improvised arrangement of aerosol delivery to the ventilator dependent patient.

Sir, The patients supported by invasive mechanical ventilation (IMV) often require aerosol therapy for bronchodilators and inhaled corticosteroids. Mucolytics, antibiotics and other medications can also be given by this method.[1] Aerosol therapy is indicated in these patients for management of asthma, bronchospasm, increased airway resistance, intrinsic positive end-expiratory pressure, difficult to wean, and ventilator dependent patients. Aerosol therapy helps in reducing work of breathing by decreasing pulmonary dynamic hyperinflation and resistance of the respiratory system.[2] Effective delivery of aerosol to the lungs depends on formulation of drug, aerosol generator, and technique of administration. Various devices are used to generate aerosol, but pressurized metered-dose inhaler (pMDI) and nebulizers are the most commonly used in patients supported by IMV. The commonly used nebulizers are the jet and the ultrasonic devices. Vibrating mesh nebulizers and intratracheal nebulizing catheters are newer aerosol generating devices. These devices are connected to the inspiratory limb of the ventilator circuit by specific adaptors attached to the artificial airway. Several ventilator parameters also affect the effective delivery of aerosol to the patient. pMDI require a specific adaptor, a spacer and synchronization with ventilator for effective delivery of aerosol. If properly administered pMDI and nebulizers are equally effective in delivery of aerosol therapy to the mechanically ventilated patients although using nebulizers is the common practice. Jet nebulizers use a jet of compressed air or oxygen, while ultrasonic nebulizers use piezo-electric crystals vibrations to produce aerosol. New vibrating mesh nebulizers use a vibrating mesh or plate with multiple apertures to generate aerosol. Jet nebulizers are cost-effective and easy to use and adding a reservoir between jet nebulizer and endotracheal tube increases aerosol delivery. Some new generation ventilators have an in-built mechanism for supporting the jet or ultrasonic nebulizers. These ventilators synchronize inspiratory flow and volume to activate the jet nebulizer intermittently during inspiration.[3] Over a period of time, these compatible jet nebulizers tend to be damaged or lost. Many ventilators are not compatible with jet nebulizers or newer aerosol therapy devices. In these situations, often a jet nebulizer operated by compressed oxygen from wall system or cylinder, is attached to the inspiratory limb of breathing circuit. A minimum flow of 6-8 L is required to generate the aerosol. The volume added by this method can affect ventilator parameters and can be very harmful, especially to the pediatric patients who have small lung volumes. Self-inflating manual resuscitator is a breathing system that uses nonrebreathing unidirectional valves. A pressure limiting device is present near inspiratory valve to prevent barotrauma in all infant/child and some adult manual resuscitators. There is a connection port to attach a reservoir bag at the bag inlet.[4] In this improvized arrangement, a T-adaptor with jet nebulizer assembly is attached to the above mentioned connection port [Figure 1]. A one-way valve [Direction, Figure 1] is attached to the free end of the T-adaptor to prevent aerosol loss and direct airflow to the bag inlet when it is re-expanding. Presence of resuscitation bag next to the jet nebulizer and addition of 3-4 mL of normal saline to the drug can help in effective delivery of aerosol. The tidal and minute volumes can be controlled manually to deliver aerosol safely to the ventilator dependent patients where compatible aerosol device is not available. Figure 1 Improvized arrangement

Assessment of essential newborn care services for low birth weight babies in rural Lucknow, India

Majority of the death during neonatal period occur due to the low birth weight. So reduction of the neonatal mortality, availability of neonatal care service especially for low birth weight babies were required at the primary and secondary health care level. For this first assessment of actual condition of health services of essential newborn care for low birth weight were required. So the objective of the study was to assess the essential newborn care services for low birth weight babies in rural Lucknow. The facility based survey was conducted from Oct 2011 to May 2012 in rural area of Lucknow district, Uttar Pradesh in 9 community health centres and 9 primary health centres. Multistage random sampling was used for the reaching up to the PHCs. For facility assessment regarding neonatal care services for low birth weight infrastructure, manpower, equipments related to newborn care were assessed. Only four (44.4%) primary health centres had separate labour room. About 11.1 percent PHCs had newborn care corner and adequate light in labour room. Only one PHC had regular electricity supply. Most of the primary health centres (77.8%) had one general duty medical officer. availability of essential newborn care equipment was found to be grossly inadequate in almost all the primary health centres. No primary health centre had baby weighing scale and radiant warmer. Majority of PHCs did not have suction pumps, resuscitation bags with masks, oxygen facilities and IV infusion facilities. There were inadequate neonatal care services at the primary health care level. For the improvement of the neonatal health, strengthening of the neonatal care services especially for low birth weight is required at primary health care level.

Tracheostomy Care and Complications in the Intensive Care Unit

Tracheotomy is a common procedure in intensive care units, and nurses must provide proper care to tracheostomy patients to prevent complications. One of the most important considerations is effective mobilization of secretions, and a suction catheter is the most important tool for that purpose. Each bedside should be equipped with a functional suctioning system, an oxygen source, a manual resuscitation bag, and a complete tracheostomy kit, which should accompany patients wherever they go in the hospital. Complications include infection, tracheomalacia, skin breakdown, and tracheoesophageal fistula. Tracheostomy emergencies include hemorrhage, tube dislodgement and loss of airway, and tube obstruction; such emergencies are managed more effectively when all necessary supplies are readily available at the bedside. This article describes how to provide proper care in the intensive care unit, strategies for preventing complications, and management of tracheostomy emergencies.

Neonatal self‐inflating bags: Achieving titrated oxygen delivery using low flows: An experimental study

To determine delivered O2 concentration (dFiO2) during manual inflations using neonatal self-inflating resuscitation bags (SIBs) at oxygen (O2) flow rates <1 L/min. This experimental study, determined dFiO2 during 216 sets of manual inflations at different O2 flow rate (L/min; 0.2, 0.4, 0.6, 0.8, 1.0 and 5.0), controlling peak inspiratory pressures (PIP; cm of H2O; 10-15, 15-20 and 20-25), inflation rates (per min; 30, 40 and 60), with and without O2 reservoir using two SIBs--the Laerdal infant resuscitator (240 mL) and Ambu Mark IV resuscitator (300 mL). A leak proof circuit connecting the SIB in series with pressure transducer, O2 analyzer and test lung was used. All possible combinations were tested four times each. The dFiO2 with each possible combination was compared using generalised estimating equation. The mean dFiO2 with SIB even without reservoirs varied with rates and PIP from 75 to 93% at O2 flow rate of 5 L/min. At 1 L/min flow itself, 65-85% O2 is delivered. The dFiO2 was reduced to approximately 40% with flow of 0.2 L/min, PIP 20-25 cmH2O and inflations 40-60 per min. During manual breaths using neonatal SIBs, the delivered O2 concentration of nearly 40% is attained at clinically used inflation pressures and rates by using lower flows. A graded increase in O2 delivery from 40 to 99% was obtained with flow varying from 0.2 to 5 L/min and addition of reservoir. However, even at such low flows, reduction in O2 concentration below 40% was unattained.

Experimental study on the efficiency and safety of the manual hyperinflation maneuver as a secretion clearance technique

OBJECTIVE: To evaluate, in a lung model simulating a mechanically ventilated patient, the efficiency and safety of the manual hyperinflation (MH) maneuver as a means of removing pulmonary secretions. METHODS: Eight respiratory therapists (RTs) were asked to use a self-inflating manual resuscitator on a lung model to perform MH as if to remove secretions, under two conditions: as routinely applied during their clinical practice; and after receiving verbal instructions based on expert recommendations. In both conditions, three clinical scenarios were simulated: normal lung function, restrictive lung disease, and obstructive lung disease. RESULTS: Before instruction, it was common for an RT to compress the resuscitator bag two times, in rapid succession. Proximal pressure (Pprox) was higher before instruction than after. However, alveolar pressure (Palv) never exceeded 42.5 cmH2O (median, 16.1; interquartile range [IQR], 11.7-24.5), despite Pprox values as high as 96.6 cmH2O (median, 36.7; IQR, 22.9-49.4). The tidal volume (VT) generated was relatively low (median, 640 mL; IQR, 505-735), and peak inspiratory flow (PIF) often exceeded peak expiratory flow (PEF), the median values being 1.37 L/s (IQR, 0.99-1.90) and 1.01 L/s (IQR, 0.55-1.28), respectively. A PIF/PEF ratio < 0.9 (which theoretically favors mucus migration toward the central airways) was achieved in only 16.7% of the maneuvers. CONCLUSIONS: Under the conditions tested, MH produced safe Palv levels despite high Pprox. However, the MH maneuver was often performed in a way that did not favor secretion removal (PIF exceeding PEF), even after instruction. The unfavorable PIF/PEF ratio was attributable to overly rapid inflations and low VT.

Oxygen Delivery Using a Neonatal Self-inflating Resuscitation Bag: Effect of Oxygen Flow

We evaluated the effect of oxygen (O₂) flow rate on the corresponding delivered fraction of oxygen (FiO₂) during positive pressure ventilation (PPV) when using a neonatal self-inflating bag (SIB). Fifteen health care professionals administered PPV at a respiratory rate of 40 to 60 breaths per minute and at peak inspiratory pressures of 25 and 35 cm H₂O to a manikin by using a SIB with reservoir connected to an O₂ source equipped with a flowmeter (flow rates: 0-10 L/min). The FiO₂ corresponding to each flow rate was measured at the inflow to the facial mask for 60 seconds. In total, 2520 FiO₂ data points were collected. At every O₂ flow rate, the FiO₂ gradually increased from time 0 seconds to time 60 seconds, both at 25 cm H₂O and at 35 cm H₂O. After 1 minute of PPV at 25 cm H₂O, the delivered FiO₂ was 31.5% ± 2.1% and 43.1% ± 3.1% at O₂ flow rates of 0.1 and 0.5 L/min, respectively. After 1 minute of PPV at 35 cm H₂O, the delivered FiO₂ was 29.4% ± 2.0% and 42.1% ± 4.6% at O₂ flow rates of 0.1 and 0.5 L/min, respectively. At all O₂ flow rates >5 L/min, the delivered FiO₂ was >85% and >95%, after 1 minute of PPV at 25 and 35 cm H₂O, respectively. Delivered FiO₂ during PPV depends on 3 factors: oxygen flow rate, peak inspiratory pressures, and time elapsed. These data can be used to develop a scheme correlating the oxygen flow rate and the corresponding delivered FiO₂ when using a neonatal SIB.

Oxygen Delivery Using a Neonatal Self-inflating Resuscitation Bag: Effect of Oxygen Flow

Oxygen Delivery Using a Neonatal Self-inflating Resuscitation Bag: Effect of Oxygen Flow

Management of bronchopleural fistula using a modified single lumen tube

Bronchopleural fistula (BPF) is defined as a pathologic connection between the tracheobronchial tree and the pleural space with persistent air leak for more than 24 hours. It is associated with poor prognosis after pneumonectomy [1], which mainly contributes to the occurrence among elective lung resections despite the outstanding advances in surgical techniques. Mechanical ventilation is always problematic for balancing the actual ventilation and the leakage in patients who present a BPF after pulmonary resections. High airway pressure to achieve sufficient minute ventilation may aggravate air leakage and interfere the healing process [2]. We describe a case in which a modified single-lumen endobronchial tube was used in a patient who developed BPF after right lower lung lobectomy in order to improve ventilation and allow adequate suctioning.

Delivered oxygen fraction during simulated cardiopulmonary resuscitation depending on the kind of resuscitation bag and oxygen flow

Emergency cases for resuscitation include built-in oxygen cylinders with limited oxygen supply. The use of a bag-valve mask device (BVMD) with a reservoir requires a high constant flow of oxygen to maintain a high concentration of delivered oxygen. The goal of the study was to analyze what fraction of inspired oxygen (FiO2) can be reached and how long it takes using different BVMD with their reservoir device and different oxygen flows in order to allow a reduction in oxygen requirements during simulated cardiopulmonary resuscitation (CPR). Experimental analysis was carried out during simulated CPR on the effect in the final FiO2 and the time required to reach it using two different models of BVMD with their reservoir device: Mark IV and Revivator-Plus and four different oxygen flows 5, 10, 15, and 10 l/min during 1 min, followed by 5 l/min (10-5). With both the BVMDs studied, the FiO2 values reached at 10, 15, and 10-5 l/min were higher than 0.85 [Mark IV=0.87 (0.01); Revivator=0.93 (0.03)] in 60 s. At 5 l/min FiO2 were lower in 60 s (P<0.001) and were higher than 0.85 [Mark IV=0.90 (0.005); Revivator=0.90 (0.005)] in 80 s. The mean FiO2 was lower with the Mark IV (P<0.05) (Table 1). To allow a substantial reduction in oxygen requirements, a 10 l/min for 1 min, followed by 5 l/min of oxygen flow can be used during CPR with both BVMDs studied. Increasing supplemental oxygen flow did not appreciably increase the FiO2.

Delivery of titrated oxygen via a self-inflating resuscitation bag

AimTo investigate whether titration of inspired oxygen can be achieved through adjustment of oxygen flow into a self-inflating resuscitation bag with a reservoir of a type used in standard ambulance practice. MethodsIn a series of bench experiments, oxygen was delivered via a flow metre to a 1500ml self-inflating resuscitation bag with a 2500ml reservoir bag and connected to a test lung. The oxygen concentration delivered to the test lung by manual inflation of the resuscitation bag was measured using an anaesthetic machine while the delivered tidal volume was measured using a respirometer. The delivered oxygen concentration was measured at flows of 0.5, 2, 6, 12 and 15lmin−1 for tidal volumes of 300, 600, and 900ml with bag inflation rates of 10, 20 and 30min−1. ResultsA wide range of delivered oxygen concentrations ranging between 24% and 99.5% were achieved with different oxygen flows, tidal volumes, and inflation rates. Overall, the mean delivered oxygen concentration increased significantly with each of the increments of oxygen flow tested (p<0.001 for all comparisons). ConclusionsEffective titration of oxygen delivery can be achieved using adjustment of oxygen flow with a standard self-inflating resuscitation bag and reservoir.

Survey of Aerosol Delivery Techniques to Spontaneously Breathing Tracheostomized Children

Therapeutic inhaled aerosols are often delivered to spontaneously breathing tracheostomized children. Although aerosol delivery can be affected by several factors, no recommendations for device/drug formulation choice are available. We hypothesized that practice modalities will vary among different institutions. The respiratory care departments in institutions in the United States that train pediatric pulmonologists were surveyed regarding their practices of delivering aerosols to spontaneously breathing tracheostomized children. Characteristics of the institution; use of metered-dose inhalers (MDIs), nebulizers, and dry powder inhalers; use of a resuscitation bag to aid aerosol delivery (assisted); types of medication used; and factors affecting choice of delivery method were recorded. Of the invited institutions, 81% (38/47) participated, with 68% of them being freestanding children's hospitals. MDIs were used by 92% of the institutions surveyed, with similar use of unassisted (32%, with 83% of them using spacers), assisted (34%, with 100% of them using non-valved spacers), and both techniques (34%). Nebulizers were used by 97% of the institutions surveyed, with all using unassisted and 32% also using assisted technique. Tracheostomy aerosol mask was the most commonly used interface (89%). Assisted technique for either MDI or nebulizer was used by 68% of the institutions surveyed, with similar use of flow-inflating bag, self-inflating bag, and both devices. Types of inhaled medications utilized by surveyed institutions included aerosolized antibiotics (82%), corticosteroids (100%), short-acting β agonists (100%), combination therapy (32%), and mucolytics (84%). Dry powders were not used. Patient cooperation was the most frequent and single most important factor influencing the choice of delivery method. A wide variation in practice of delivering aerosols to spontaneously breathing tracheostomized children was noted. In-vivo and in-vitro studies are needed to support clinical recommendations.

An In Vitro Evaluation of Aerosol Delivery Through Tracheostomy and Endotracheal Tubes Using Different Interfaces

Previous research reporting factors influencing aerosol delivery in intubated patients has been largely focused on the endotracheal tube (ETT) during mechanical ventilation, with little comparative analysis of effect of types of artificial airways and their interfaces on aerosol delivery during spontaneous breathing. The purpose of this study was to compare aerosol delivery via tracheostomy tube (TT) and ETT, using interfaces such as T-piece, tracheostomy collar, and manual resuscitation bag. A teaching manikin was intubated with either an ETT (8.0 mm inner diameter) and TT (8 mm inner diameter). Both bronchi were connected to a collecting filter, attached to a sinusoidal pump simulating the breathing pattern of a spontaneously breathing adult (tidal volume 450 mL, respiratory rate 20 breaths/min, inspiratory-expiratory ratio 1:2). Albuterol sulfate (2.5 mg/3 mL) was nebulized through a jet nebulizer, using each airway and interface as appropriate (n = 3). Drug on the filter was eluted and analyzed with spectrophotometry, and expressed as mean percent of loaded dose delivered. Descriptive statistics, the Student t test, and one-way analysis of variance were applied. A greater percentage of nominal dose was delivered via TT than ETT with both T-piece (13.79 ± 2.59% vs 9.05 ± 0.70%) and manual resuscitation bag (45.75 ± 1.8% vs 27.23 ± 8.98%, P = .038 and P = .025, respectively). Use of manual resuscitation bag with both TT and ETT increased lung dose more than 3-fold. Inhaled dose with tracheostomy collar was (6.92 ± 0.81%) less than T-piece with TT (P = .01). In this adult model of spontaneous ventilation, aerosol therapy through ETT was less efficient than TT, while the manual resuscitation bag was more efficient than T-piece or tracheostomy collar.

An Evaluation of Peak Inspiratory Pressure, Tidal Volume, and Ventilatory Frequency During Ventilation With a Neonatal Self-Inflating Bag Resuscitator

Although the self-inflating bag is widely used in the hospital setting, variability of delivered ventilatory parameters is usually high, which might result in both hypoventilation and lung injury. The aims of this study were to assess possible sources of the high variability and to evaluate the adequacy of obtained values in relation to the recommended values for neonatal resuscitation. This was an experimental study in which 172 health professionals (physicians, resident physicians, physiotherapists, nurses, and nursing technicians) who work with neonatal intensive care manually ventilated a test lung (adjusted to simulate the lungs of an intubated term newborn) with a self-inflating bag in 5 different handling techniques, using 10, 5, 4, 3, and 2 fingers. Delivered values of peak inspiratory pressure (PIP), tidal volume (V(T)), and ventilatory frequency (f) were compared, taking into account the different handling modalities and professions by analysis of variance for repeated measures. Chi-square, the Friedman test and the Fisher exact tests were performed to compare the delivered and standard values. PIP and V(T) were significantly affected by the handling technique, with higher values for a greater number of fingers used for ventilation. Profession also influenced V(T) and f significantly: physiotherapists tended to deliver higher volumes and lower rates. Nevertheless, we observed high variability of all studied ventilatory parameters and overall inadequacy of obtained values. Most volunteers delivered excessive pressures and volumes at insufficient ventilatory frequency. Delivered values seem to depend on operators' individual and professional differences, as well as on the number of fingers used to compress the bag. However, from the clinical point of view, it is important to point out the high occurrence of inadequate delivered values, regardless of handling technique and profession.

Lung Volume Recruitment Slows Pulmonary Function Decline in Duchenne Muscular Dystrophy

McKim DA, Katz SL, Barrowman N, Ni A, LeBlanc C. Lung volume recruitment slows pulmonary function decline in Duchenne muscular dystrophy. ObjectiveTo evaluate the long-term effect on measures of forced vital capacity (FVC) before and after the introduction of regular lung volume recruitment (LVR) maneuvers (breath-stacking) in individuals with Duchenne muscular dystrophy (DMD). DesignRetrospective cohort study of pulmonary function data, including FVC, cough peak flow (CPF), maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP). Data were collected for 33 months prior to and 45 months after LVR introduction. SettingAmbulatory care in a tertiary level regional rehabilitation center in Canada. ParticipantsAll individuals (N=22) with DMD (mean age ± SD, 19.6±2.4y), who were prescribed LVR and reported adherence with therapy. InterventionsIntroduction of regular LVR (breath-stacking); 3 to 5 maximal lung inflations (maximum insufflation capacity [MIC]) using a hand-held resuscitation bag and mouthpiece, twice daily. Main Outcome MeasuresMeasures included the rate of decline of FVC in percent-predicted, before and after the introduction of regular LVR. Changes in maximum pressures (MIP, MEP), MIC, and cough peak flows were also measured. ResultsAt LVR initiation, FVC was 21.8±16.9 percent-predicted, and cough peak flows were <270L/min (144.8±106.9L/min). Annual decline of FVC was 4.7 percent-predicted a year before LVR and 0.5 percent-predicted a year after LVR initiation. The difference, 4.2 percent-predicted a year (95% confidence interval, 3.5–4.9; P<.000), represents an 89% improvement in the annual rate of FVC decline. ConclusionsThe rate of FVC decline in DMD patients improves dramatically with initiation of regular LVR.

Choking Carries Significant Risk for Residents and Facilities

Choking Carries Significant Risk for Residents and Facilities

エンドスコピーマスクと蘇生バッグを用いた病棟でのファイバースコープガイド下気管挿管法

エンドスコピーマスクと蘇生バッグを用いた病棟でのファイバースコープガイド下気管挿管法

Sensing and Responding to Compliance Changes during Manual Ventilation Using a Lung Model: Can We Teach Healthcare Providers to Improve?

To test the hypothesis that an educational intervention would improve the resuscitator's ability to provide on-target volume ventilation during pulmonary compliance changes. Neonatal professionals (n = 27) ventilated an electromechanical lung model simulating a 3-kg baby while targeting a tidal volume of 4-6 mL/kg. In this preintervention and postintervention study, a one-on-one educational intervention aimed to improve the primary outcome of on-target tidal volume delivery during high and low compliance. Seventeen subjects were retested 8 months later. When only pressure was displayed, and using a self-inflating bag, participants improved from a mean of 6% of breaths on-target to 21% immediately after education (P < .01). Using a flow-inflating bag, participants improved from 1% to 7% of breaths on-target (P < .01). Eight-month retention testing demonstrated no difference compared with baseline. With volume displayed, the mean baseline success rate was 84% with the self-inflating bag and 68% with the flow-inflating bag. There was no significant change after education or at 8-month follow-up. When pressure is displayed, resuscitators can improve their ability to respond to changes in compliance after an educational intervention. When volume is displayed, performance is markedly better at baseline, but not improved after the intervention. Our findings reconfirm that resuscitation bags should have volume displays.

‘Breath Stacking’ Reported to Make Swallowing Safer in ALS

ORLANDO, FL—A simple breathing technique that takes only minutes to learn can help most patients with amyotrophic lateral sclerosis (ALS) not only coug h more effectively but also swallow more safely. The technique, called “breath stacking,” has been known to improve cough for almost two decades. A new study has shown that it also increases the patient’s ability to protect the airway during swallowing, lowering the risk of aspiration and choking. “This is a very important approach to therapy that can make a big difference to our patients in terms of both quality of life and length of life,” said Robert G. Miller, MD, director of the Forbes Norris MDFA/ALS Research Clinic at California Pacifi c Medical Center in San Francisco, who was not involved in the study. “Unfortunately, relatively few neurologists are familiar with it.” Study investigator Stuart Cleary, PhD, assistant professor of speech pathology and audiology at the University of Alberta in Edmonton, described the fi ndings here at the ALS-MND Society meeting here in December. Breath stacking is meant to interrupt a cycle of poor airway maintenance that is typical in ALS. As breathing muscles weaken, the ability to cough is impaired, leading to accumulation of mucus plugs in the smaller airways. At the same time, poor airway protection during swallowing increases the risk of aspiration. The breath stacking maneuver is simple, Dr. Cleary explained. The patient uses a resuscitator bag equipped with a one-way valve and mouthpiece to take a series of breaths without exhaling, expanding the lungs beyond what he or she can accomplish with a single breath. The resulting stretching of the lungs and chest wall opens clogged airways and increases chest compliance, leading to reduced airway resistance to airfl ow. “This translates to improved lung volumes, higher peak cough fl ows and improved airway clearance,” he said. “As a swallowing therapist, I am interested in protecting the airway during mealtime,” Dr. Cleary said. Anecdotal reports from ALS centers in Canada, where the practice is somewhat more common, indicated the technique seemed to improve swallowing safety, so he set out to test that in a rigorous fashion. Dr. Cleary enrolled 29 ALS patients with a mean age of 65 years, a median ALS Functional Rating Scale score of 28 out of 48, a mean forced vital capacity (FVC) of 58 percent of predicted, and a mean peak cough fl ow (PCF) of 245 L/min. Participants performed fi ve trials of breath stacking, each separated by about 20 seconds. Respiratory and swallowing tests were performed before treatment, and at 15 and 30 minutes afterward. Patients served as their own controls, performing the same tests on different days without breath stacking. Consistent with previous studies, peak cough fl ow improved following breath stacking, rising approximately 50 L/min following treatment, an increase which lasted 30 minutes after treatment. The difference was signifi cant for both time points versus baseline and versus the control value. Dr. Cleary also found that breath stacking improved patients’ ability to perform other airway-clearing techniques, such as throat clearing and “hawking,” as well as the supraglottic swallowing maneuver, which consists of holding one’s breath while swallowing, closing the vocal cords and protecting the airway. The combined effect, Dr. Cleary said, is that for up to 30 minutes after breath stacking, ALS patients were better able to cough, to clear mucus or food stuck in throat, and to swallow safely.