Transcript The Vest™ airway clearance system Medi

Airway Clearance in Children
Youth and Adolescents – Does
The Device Really Matter?
Chris Landon MD FAAP,FCCP,CMD
Director of Pediatrics Ventura County Medical Center
Pediatric Pulmonary Center Director Mid Coast
Clinical Associate Professor of Pediatrics USC School of Medicine
Pediatric Pulmonary Department Children’s Hospital Los Angeles
Disclaimer
Scientific Advisory Boards
•
Hill-Rom
Objectives
• I. Review of the rationale for airway clearance
therapy and basic principles
• II. Review the evidence for efficacy of airway
clearance therapy in pediatrics
• III. Minimal to no benefit in the treatment of
children with acute asthma, bronchiolitis,
hyaline membrane disease, and those on
mechanical ventilation for respiratory failure
in the pediatric intensive care unit, and it is
not effective in preventing atelectasis in
children immediately following surgery.
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Neuromuscular Diseases: Overview
Children who experience varying
degrees of neurological/neuromuscular
dysfunction
Diagnoses include: cerebral palsy,
muscular dystrophy, spinal muscular
atrophy, brain injury, consequences of
infectious disease, inherited metabolic
disorders, etc.
– One child in 1000 is institutionalized as a
result of profound disability
Neuromuscular Diseases: Overview
Multi-system assessment necessary to
determine risk of pulmonary involvement:
Neuromuscular
Gastroesophageal
Immune system
Respiratory
Psychosocial
Neuromuscular Diseases
Assessment of complications that
predispose to pulmonary involvement
• Neuro assessment – Oral
motor weakness
 Typical symptoms
– Muscular dystrophies
– Too weak to swallow
– Myopathies
– Too weak to cough
– Neuromuscular
junction disorders
– Easily fatigued
– Anterior horn cell
disorders
– Head position
dependent
Neuromuscular Diseases
Assessment of complications that
predispose to pulmonary involvement
• Neuro assessment –
Increased secretions
– Autonomic dysfunction
– Medication effects
– Frequent seizures
 Typical symptoms
– Constant drooling
– Worse with stress or
infection
– Drowning in drool
Oral Motor Weakness
Myopathies
Muscular dystrophies
Neuromuscular junction disorders
Anterior horn cell disorders
Typical symptoms
– Too weak to swallow
– Too weak to cough
– Easily fatigued
– Head position dependent
Central Neurogenic Hypoventilation
Diffuse cortical damage
Poor hypoxic response
Poor hypercarbic response
Worse with stress or infection
Thoracic Weakness
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Myopathies
Muscular dystrophies
Neuromuscular junction disorders
Anterior horn cell disorders
Gastroesophageal Function and
Complications
 The Upper AirwaySwallowing and
Aspiration
 Aspiration Associated
Pneumonias
 Lower Esophageal
Aspiration, Gastric
Distention and Airway
Remodeling
 Gastroesophageal
Reflux Disease (GERD)
 Fundoplication Versus
Medication and Airway
Clearance
 Nutrition and the
Immune System
The Faces of Dysfunction
Arching
Failure To Thrive
Irritability
Gagging and Choking
Regurgitation
Refusing Feedings
The Immune System
 Genetic
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Abnormalities
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 Nutritional
Compromise of the
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Immune System
 Stress and Immune
Response
 Recurrent Infection
and Frequent Use of
Antibiotics: The
Impacts
Allergies
Reactive Airway
Disease (RAD)
Airway Clearance
Therapy
Respiratory Medical History
–
Number of Pulmonary Infections Annually
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Number of Hospital Admissions Annually
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Number of ER Admissions Annually
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Number of Courses of Antibiotics for Respiratory
Infections Annually
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Immunization History
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History of Recurrent Infections with Respiratory
Syncytial Virus (RSV)
High Risk For Post-Operative
Complications
 Atelectasis
 Pneumonia
 Respiratory Failure
 Need for prolonged
ventilation
 Tracheostomy
 Death
Problems
 Weak cough
 Dyscoordinated swallow
 Aspiration
 Difficulty clearing secretions
 Increased lower respiratory tract
infections
Respiratory Weakness
 May not be apparent on physical exam
 Respiratory failure when work of
breathing is increased
Chronic Respiratory Muscle Weakness
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Reduced lung volumes
Microatelectasis
V/Q mismatch
Scoliosis
Decreased compliance of the chest wall
Decreased pulmonary compliance
Hypoxemia only during sleep
Hypoventilation due to muscle weakness
Hypoventilation due to central hypoventilation
Thorough History
 Frequency and severity of respiratory tract
infections
 Pulmonary complications of previous
surgeries
 History suggestive of reactive airways
disease
– Even mildly increased airway obstruction
may lead to respiratory failure in the
postoperative period in a patient with
severe respiratory muscle weakness
Physical Examination
Gag reflex
Cough
Adequacy of aeration
Presence of adventitial lung
sounds
Ability To Cooperate With PostOperative Pulmonary Therapy
 General muscle strength
 Physical and intellectual capacity
Laboratory Examinations
Chest x-ray
Arterial blood gases or mixed
venous gas measurements and
oximetry
Complete blood count
Pulmonary Function Tests
 All children who are capable of performing them
– Lung volumes
– Pre and post bronchodilator
– Maximal inspiratory and expiratory mouth
pressures
• frequently decreased more than lung
volumes and flows
• do not correlate with general muscle
strength
Impaired Airway Clearance: Factors
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Ineffective mucociliary clearance
Excessive secretions
Thick secretions
Ineffective cough
Restrictive lung disease
Immobility / inadequate exercise
Dysphagia / aspiration / gastroesophageal
reflux
Results of Impaired Airway Clearance
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Airway obstruction
Mucus plugging
Atelectasis
Impaired gas exchange
Infection
Inflammation
Disease States with Compromised
Airway Clearance
• Primary Ciliary Dyskinesia
• Neuromuscular Disease
– Predisposes to respiratory failure
– Distinct risk factor for morbidity and mortality
• Severe neurologic insults
• Cystic Fibrosis
• Bronchiectasis
 No proven benefit for airway clearance therapy in pneumonia,
asthma not complicated by atelectasis, bronchiolitis
Airway Clearance Devices
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CPT for infants
PEP Valve
Flutter
Acapella
Cough Assist
The Vest System
Chest Physiotherapy for Infants
• No definitive data to support use in
asymptomatic CF infant.
• Most likely age group to have adverse
effects, especially GER + aspiration.
• Must modify postural drainage to minimize
side effects
• Significant time commitment for families and
Healthcare teams
PEP Valve
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Positive Expiratory Pressure
Action: Splints airways during exhalation
Can be used with aerosolized medications
Technique dependent
Portable
Time required: 10-15 minutes
Flutter
• Action: Loosens mucus through expiratory
oscillation; positive expiratory pressure
splints airways.
• Used independently
• Technique dependent – has to be held at
a precise angle to maximize oscillation
• Portable
• May not be effective at low airflows
• Time required: 10-15 minutes
Acapella
• Combines benefits of PEP and airway
vibrations to mobilize secretions
• Similar to flutter except has a valvemagnet device to interrupt expiratory flow
and thus can be used at any angle.
Contraindications for PEP, Acapella
and Flutter
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Pneumothorax
Perforated ear drum
Hemoptysis
Post-operative lung surgery as may lead
to air leak or if fresh transplant may break
down anastomoses site
• Severe cardiac disease
• Esophageal varices
• Pulmonary embolus
Cough Assist
• Action: Creates mechanical “cough” through the
use of high flows at positive and negative pressures.
• Positive / negative pressures up to 60cm of water
• Used independently or with caregiver assistance
• Technique independent
• Portable
• Primary use in muscular weakness
Airway Clearance Vest Systems
(High Frequency Chest Wall Oscillation)
High Frequency Chest Wall Oscillating
Devices
• Action: Uses pulses of air pressure
applied to the chest wall to produce
shearing at the air-mucus interface and
compression causes repetitive peak
expiratory flows to expel mucus like small
coughs
• The chest wall is only compressed
• The air in the airways only oscillates
Contraindications to Vest Therapy
• Head and/or neck injury which has not
been stabilized
• Active pulmonary hemorrhage
• Hemodynamic instability
Quality Airway Clearance Therapy
Should
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Clear secretions effectively and consistently
Preserve lung function
Reduce infectious exacerbations
Reduce dependence on antibiotic therapy and
other medications
Reduce need for hospitalization and auxiliary
medical services
Delay disease progression
Reduce the burden of care
Enhance the quality of life
Adverse Effects – Airway Clearance
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Oxygen desaturation
Gastroesophageal reflux
Aspiration
Hyperventilation
Airway obstruction from mobilized secretions
Barotrauma
Pain and discomfort
Guilt from lack of adherence
Therapy Adjuncts
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Antibiotics
Bronchodilators
Anti-inflammatory drugs
Mucolytics
Nutrition
HFCWO Clearance System Case
5 Year Old Girl With Spinal
Muscular Atrophy Second PICU
Hospitalization in Two Months
History Of Illness
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5 year old girl with Spinal Muscular Atrophy
Fever and oxygen saturations in the high 80’s
Discharged from PICU two weeks prior
Poor oral intake
Clinical Findings
• X-ray at PMD’s office showed RUL Pneumonia
• Transferred by PMD to Santa Barbara PICU by
ambulance from the office
• Temperature 38.7 Pulse 158 BP 105/53
• Respiratory Rate 29
• Chest clear to auscultation bilaterally. No
audible wheezing
• Neuro – Alert and cooperative, extremely thin
with muscular atrophy
Treatment Issues
• Social stressors of divorcing parents
• Parents not recognizing that patient is having difficulties
with eating
• Last authorized Pediatric Pulmonary visit 1/23/05 VEST
prescribed
• Despite multiple attempts to fit VEST, patient reported to
mother it was uncomfortable. Mother blamed father for
imposing it. Parents feel uncomfortable with CPT due to
patients reported discomfort
• Unable to generate sufficient flow for Flutter and Acapella
• Patient has nebulizer for albuterol and uses 1992
Coffalator left by DME company
Exam Date: 1/19/2006 13:55
Hours
PROCEDURE: X-RAY OF CHEST
ONE VIEW, PORTABLE
COMPARISON:12/3/05.
INDICATIONS: Fever, cough.
FINDINGS: When compared with
the previous study there is now
an area of opacity in the right
upper lobe.
CONCLUSION: Right upper lobe
pneumonia.
Medical Interventions at Time of
Presentation
• BiPap with supplemental oxygen for sleeping
and napping
• Cefuroxime and Azithromycin
• Patient receives albuterol and CPT to upper lobe
PROCEDURE: X-RAY OF CHEST ONE
VIEW, PORTABLE
COMPARISON:1/20/06
INDICATIONS Pneumonia
FINDINGS: There is rotation to the right.
There is increased opacity in the right
hemithorax. There is evidence of shift
of the mediastinal contents to the right
but this is accentuated due to rotation.
The relatively rapid increase in opacity
is suspicious for atelectasis. The left
lung remains clear.
CONCLUSIQN~ Marked increase in
parenchymal opacity in right
hemithorax with evidence for volume
probably representing lobar
atelectasis.
Medical Interventions at Time of
Presentation
• BiPap with supplemental oxygen for
sleeping and napping
• Cefuroxime and Azithromycin
• Changed to cefepime on Day 3
• Pediatric Hospitalist reviews care and Xray reports by phone with Pediatric
Pulmonologist
• Coffalator brought from home
Exam Date: 1/21/2006 9:41 Hours
COMPARISON; 1/20/06
INDICATIONS: Pneumonia
FINDINGS: There is rotation to the right.
There is increased opacity in the right
hemithorax. There is evidence of shift of
the mediastinal contents to the right but
this is accentuated due to rotation. The
relatively rapid increase in opacity is
suspicious for atelectasis. The left lung
remains clear.
CONCLUSION: Marked increase in
parenchymal opacity in right hemithorax
with evidence for volume loss, probably
representing lobar atelectasis.
Medical Interventions at Time of
Presentation
• BiPap with supplemental oxygen for sleeping
and napping
• Cefuroxime and Azithromycin
• Changed to cefepime on Day 3
• Coffalator brought from home
• Custom VEST brought from home and used in
conjunction with Coffalator
PROCEDURE: X-RAY OP CHEST
ONE VIEW, PORTABLE 1/25/06
COMPARISON: 1/23/06
INDICATIONS: PNA
FINDINGS:
There is patchy right
lung infiltrate which is slightly
improved since the previous exam
with improved volume loss in the
right chest. The patient is rotated.
Gracile ribs suggest muscular
disease. The heart and
mediastinum are relatively
unremarkable.
CONCLUSION: Improving right lung
infiltrate with re-expansion of the
right lung since the previous exam.
Exam Date:
1/27/2006
PROCEDURE:X-RAY OF CHEST
ONE VIEW, PORTABLE
COMPARISON:1/25/2006.
INDICATIONS: Pneumonia.
FINDINGS:The patient is rotated.
There is evidence of
neuromuscular disease with
gracile ribs and humeri.
There is further clearing of right
lung infiltrate since previous
examination.
CONCLUSION: Further interval
clearing of right lung infiltrate.
New Achievements
• PROBLEM:
• Recurrent Intensive Care Unit
Admissions for Patients with
Neuromuscular Disease, Cerebral
Palsy, and Anoxic Brain Damage
Respiratory Management of Pediatric Patients with Chronic Pulmonary Involvement
AMDA's 27th Annual Symposium March 24, 2004
Data Sources
• Medical claims data from 2007-2009. 233,562 patients
identified with neuromuscular diseases. 446 patients
received The Vest System.
• Thomson Reuters MarketScan Data Base reflecting the
health experiences of employees and dependents covered
by the health benefits of large employers employers.
• Milliman’s Consolidated HCG Database (CHSD) containing
detailed claims and membership information from
Milliman’s data contributors
• Claims and membership from the Center of Medicare and
Medicaid Services (CMS) 5% sample of the Medicare
population
This report was prepared by Milliman on January 16, 2012
Medical Claims Analysis
• Medical claims analysis to examine the
effectiveness of High Frequency Chest Wall
Oscillation (HFCWO) in reducing medical costs.
• The analysis covered 446 neuromuscular disease
patients that had received HFCWO therapy
between 2007 and 2009 comparing health care
costs incurred before and after HFCWO therapy
intervention.
• The results of the study show lower claim costs
for patients with neuromuscular disorders after
the initial insurance claim for HFCWO.
This report was prepared by Milliman on January 16, 2012
Milliman Actuarial Analysis
Medical claims analysis examined effectiveness of HFCWO in reducing
medical costs to 446 NM pts. Receiving HFCWO between 2007-2009
Commercial Claims
• Overall Per Member Month (PMPM) claims costs
(excluding RX) were lower by 10.0%
• Inpatient admissions per 1000 were lower by 21.3%
• Inpatient days per 1000 were lower by 38.3%
• Decrease in average length of stay from 11.6 to 9.1
days
Medicare Claims
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Overall PMPM claim costs were lower by 8.2%
Inpatient admissions per 1000 were lower by 16.1%
Inpatient days per 1000 were lower by 37.8%
Decrease in average length of stay from 10.1 to 7.5
days
57
References
• Deboeck et al. Airway clearance techniques to treat acute
respiratory disorders in previously healthy children – where is the
evidence? European Journal of Pediatrics. 2009
• Fuhrman et al. Pediatric Critical Care. 4th Edition. 2011.
• Light et al. Pediatric Pulmonology. 2011
• Mcilwaine, M. Physiotherapy and airway clearance techniques and
devices. Pediatric Respiratory Review. 2007.
• Morrison and Agnew. Oscillating devices for airway clearance in
people with cystic fibrosis. Cochrane Database of Systematic
Reviews. 2009.
• Taussig et al. Pediatric Respiratory Medicine. 1999.
• West. Respiratory Physiology – The Essentials. 8th Edition 2008.
• Landon. Novel methods of ambulatory physiologic monitoring in
patients with neuromuscular disease. Pediatrics 2009