Guest guest Posted May 14, 2002 Report Share Posted May 14, 2002 The following website's are lengthy and should be read carefully. For those who have an interest, may I suggest copying to Word for reading in your spare time. Have a great week. Pulmonary Care PediDyne: Children: Drainage http://www.kci1.com/pedidyne.htmlhttp://www.kci1.com/pedidyne.html The Pulmonary Exam This 12 minute video from the University of North Carolina is part of their series of a high-quality, well-designed videos that are very useful in familiarizing students with general clinical exams. Click Here: http://oisvideo2.med.unc.edu/mpac/pulmonaryexm.ramhttp://oisvideo2.med.u\ nc.edu/mpac/pulmonaryexm.ram ------------------------------------------------------------------------------ ----------------------------------------- This commercial website contains a recorded library of 13 high-quality lung sounds. There are examples of normal, bronchovesicular, bronchial, and tracheal lung sounds as well as examples of wheezes (3 recordings), crackles (3 recordings), stridor, squawks, and grunting (in an infant). Each sound is accompanied by a text description as well as a respirosonogram. The site has numerous links encouraging purchase of a more comprehensive software program. Sound files are available in RealAudio or WAV format. (Downloadable Demo) Best Features: High quality recordings of lung sounds (normal and abnormal) Click Here: http://www.rale.ca/http://www.rale.ca/ ------------------------------------------------------------------------------ ------------------------------------------ The Chest Exam In this 11-minute video, from the University of Virginia, the examining physician performs a basic chest exam, including inspection and percussion of the lungs and auscultation of the heart. She does an excellent job of demonstrating what is being done at each step while simultaneously narrating. The entire exam is reviewed at the end. This video is not as in depth as other videos that focus on either the cardiovascular or lung exam. No heart/lung sounds included. Video quality is quite good. QuickTime plugin and high-speed Internet connection required. Click Here: http://hsc.virginia.edu/med-ed/pom/videos/chest.htmlhttp://hsc.virginia.\ edu/med-ed/pom/videos/chest.html ------------------------------------------------------------------------------ ----------------------------------------- Screening Physical Exam – Pulmonary Exam This site from Loyola University consists of bulleted text reviewing the steps of a lung exam accompanied by still images. The site demonstrates tracheal palpation, chest inspection, voice transmission, lung percussion, and lung auscultation. Each step consists of a basic text protocol with accompanying photographs, brief description and/or images of abnormal conditions, background information ( " knowledge base " ), and a self-evaluation page. For some procedures (e.g., chest exam), QuickTime videos demonstrate the protocol. Normal and abnormal breath sounds are included. This site provides an effective way for students to review the steps of the pulmonary exam. Click Here: http://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/contents.htmhttp://www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/pd/contents.htm ------------------------------------------------------------------------------ ------------------------------------------ Respiratory Sound Comparator: This is a great visual website Left side drop down menu. I used AIF uncompressed to listen to the Lung Rale Sound. Turn your volume up Virtual Stethoscope Physical Examination Pathophysiology Click Here: http://sprojects.mmip.mcgill.ca/mvs/http://sprojects.mmip.mcgill.ca/mvs/\ --------------------------------------------------------------------- Respiratory Examination This single web page from the University of Florida (a section of their physical exam study guide pages) provides a text protocol of a pulmonary exam, including inspection, palpation, percussion, auscultation, peak flow, and sound transmission. A few images accompany the text. This is intended to a quick overview of each step. Click Here: http://www.medinfo.ufl.edu/year1/bcs/clist/resp.htmlhttp://www.medinfo.u\ fl.edu/year1/bcs/clist/resp.html Clinical Skills: http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=4 " >Abdominal Exam (Includes 4 Sites) http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=23 " >ACLS Protocol (Includes 1 Site) http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=8 " >Breast Exam (Includes 1 Site) http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=2 " >Cardiovascular Exam (Includes 11 Sites) http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=27 " >ECG Interpretation (Includes 4 Sites) http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=25 " >General Physical Exam (Includes 5 Sites) http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=1 " >HEENT Exam (Includes 7 Sites) http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=26 " >History Taking and Interviewing (Includes 2 Sites) http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=11 " >Lumbar Puncture (Includes 5 Sites) http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=6 " >Musculoskeletal Exam (Includes 6 Sites) http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=5 " >Neurological Exam (Includes 8 Sites) http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_List.asp?skil\ lID=3 " >Pulmonary Exam (Includes 7 Sites) Coverage Policy BulletinsNumber: 0067 Subject: Airway Clearance Devices Policy Aetna U.S. Healthcare® covers the following airway clearance devices to assist in mobilizing respiratory tract secretions for patients with the indicated conditions that inhibit mucous clearance. ABI Vest, formerly known as theThAIRapy Vest (cystic fibrosis) Mechanical percussors (cystic fibrosis, chronic bronchitis, bronchiectasis, immotile cilia syndrome, asthma) Flutter (cystic fibrosis, bronchitis, bronchiectasis, asthma) Positive Expiratory Pressure (cystic fibrosis, chronic bronchitis, asthma) Aetna U.S. Healthcare does not cover the following airway clearance devices as there is insufficient evidence supporting their effectiveness: Intrapulmonary Percussive Ventilator (IPV) In-Exsufflator Background Cystic fibrosis (CF), chronic bronchitis, bronchiectasis, immotile cilia syndrome, asthma, and some acute respiratory tract infections can lead to abnormal airway clearance or increase sputum production. Airway secretions are cleared by mucociliary clearance (MCC), in addition to other mechanisms such as cough, peristalsis, two-phase gas-liquid flow and alveolar clearance. The underlying pathology of abnormal airway clearance differs from one illness to another. Chest physiotherapy (CPT) is a treatment program that attempts to compensate for abnormal airway clearance. By removing mucopurulent secretions, it decreases airway obstruction and its consequences, such as atelectasis and hyperinflation; furthermore, physiotherapy can decrease the rate of proteolytic tissue damage by removing infected secretions. Methods to improve removal of tenacious lung secretions in patients with CF contribute to slowing the decline in respiratory function. The standard dependent method of pulmonary care remains clapping, vibration and compression, together with postural drainage and assisted coughing. Most practitioners prescribe 20 to 30-minute CPT sessions one to three times a day, depending on the severity of disease and the presence of intercurrent infection. Problems with conventional CPT include the necessity for assistance during administration that causes children and adults to be less likely to comply. In an attempt to address this problem, different types of airway clearance techniques are now available which allow for independent use or minimal assistance by others. When a competent care giver is not available to administer CPT manually, specific alternative methods may be utilized. Many of these techniques have been developed and studied using CF patients. ABI Vest The ABI Vest, formerly known as theThAIRapy Vest, (American Biosystems, St. , MN) is an inflatable vest connected to a compressor that provides external high-frequency chest wall oscillation. The vest is connected via tubing to an air pulse delivery system. The patient then uses a foot pedal to apply pressure pulses that cause the vest to inflate and deflate against the thorax creating an oscillatory or vibratory motion. The ABI Vest has been shown to increase sputum production in CF patients; however, high frequency chest compression vests have not been proven to be more effective than manual chest physiotherapy. It can be used in place of, or as an adjunct to, manual chest physiotherapy for patients with CF. The ABI Vest has 510(k) status with the FDA (approval for marketing). The vest is only available for purchase (it cannot be rented); the air pulse delivery system (an air-pulse generator) and flexible hoses are available for rental or purchase. Requests for the ABI Vest should be reviewed by a nurse case manager who will discuss the financial options and warranties available to Aetna U.S. Healthcare if the vest needs to be replaced because it is damaged and cannot be repaired or due to a change in the patient’s physical condition. Mechanical Percussors The purpose of percussion is to apply kinetic energy to the chest wall and lung at regular intervals. Percussion is also referred to as cupping, clapping, and tapotement. It can be accomplished by rhythmically striking the thorax with a cupped hand or a mechanical device applied directly over the lung segment(s) being drained. According to the guidelines developed by American Association for Respiratory Care (AARC) on postural drainage therapy, no convincing evidence demonstrates the superiority of one method over the other; however, use of a mechanical percussor can benefit the patient by allowing for independence and greater compliance. Flutter: Photograph, how to use etc., Click on this website, () Click Here: http://www.axcanscandipharm.com/products/flutter_use.htmlhttp://www.axca\ nscandipharm.com/products/flutter_use.html The Flutter (Scandipharm, Birmingham, AL) is a handheld pipe-like device with a plastic mouthpiece on one end that the patient exhales into. On the other end of the pipe, a stainless steel ball rests inside a plastic circular cone. When the patient exhales into the device, the ball rolls and moves up and down, creating an opening and closing cycle over a conical canal. The cycle repeats itself many times throughout each exhalation intending to produce oscillations of endobronchial pressure and expiratory airflow which will vibrate the airway walls and loosen mucus so that it can be easily expectorated by the patient. The Flutter device has 510(k) status with the FDA. Although the Flutter device has not been shown to significantly change respiratory assessment parameters or pulmonary function, some patients may prefer this method over other therapies. Positive Expiratory Pressure (PEP) The PEP mask/mouthpiece contains a valve that increases resistance to expiratory airflow. The patient breathes in and out 5 to 20 times through the flow resistor, creating positive pressure in the airways during exhalation. The pressure generated can be monitored and adjusted with a manometer. Either low pressures or high pressures are prescribed. The PEP mask/mouthpiece achieves the same goal as autogenic drainage (a special breathing technique aimed at avoiding airway compression by reducing positive expiratory transthoracic pressure) by expiring against an external airflow obstruction. Most studies on the effectiveness of PEP have been conducted in Europe and they reported short-term equivalency of PEP to other methods of airway clearance. A published review of these studies found that PEP had similar effects on sputum clearance when compared with other methods (postural drainage forced exhalatory technique). The strongest evidence of the effectiveness of PEP comes from a 1-year randomized controlled clinical trial of PEP vs. conventional physiotherapy in 40 children with CF. The patients treated with PEP showed improvements in pulmonary function, whereas pulmonary function actually declined in patients treated with conventional physiotherapy. The differences between treatment groups were statistically significant for changes in FVC and FEV1. There are numerous PEP Mask/PEP Valves on the market. Examples include: Resistex PEP Mask (Mercury Medical, Clearwater, FL), TheraPep Valve (DHD, Inc., Canastota, NY), and PARI PEP Mask (PARI Respiratory Equipment, Inc., Midlothian, VA). Intrapulmonary Percussive Ventilator (IPV) Further information on this company: Click Here: http://personalnbnet.nb.ca/normap/nebulizers.htmhttp://personal.nbnet.nb\ ..ca/normap/nebulizers.htm Intrapulmonary Percussive Ventilator (IPV) (Percussionaire Corporation, Sandpoint, ID) is an aeorsol machine that delivers a series of pressurized gas minibursts at rates of 100-225 cycles per minute to the respiratory tract. Aerosolized medications can be delivered under pressure and with oscillations that vibrate the chest. In contrast to PEP and flutter, IPV allows continuous monitored positive pressure application and percussion throughout the respiratory cycle. The patient controls variables such as inspiratory time, peak pressure and delivery rates. The Percussionaire has 510(k) status with the FDA. There is a scarcity of scientific data to support the effectiveness of the device. Informal accounts from practitioners have reported favorable outcomes, and a small study (n=16) by Homnick, et al. (1995) found IPV as effective as standard aerosol and chest physiotherapy in preserving lung function. However, a recent study by Newhouse, et al. (1998) concluded that larger and longer studies of IPV compared to standard chest physiotherapy are needed to evaluate its value for independent administration of chest physiotherapy. Please note the most recent date is 1998. Four years later could prove this device acceptable or superior ( Sebastian) Mechanical Insufflation-Exsufflation- Cough Assist Click Here: http://www.jhemerson.com/http://www.jhemerson.com/ Mechanical insufflation-exsufflation (Cough Assist, J.H. Emerson Co., Cambridge, MA) (also known as In-Exsufflator, Cofflator, cough machine) is designed to inflate the lung with positive pressure and assist cough with negative pressure; it is advocated for use in patients with neuromuscular diseases. The published literature on the effectiveness of mechanical insufflation-exsufflation consists of review articles, case reports, retrospective analyses, and small uncontrolled case series. In addition, published research on mechanical insufflation-exsufflation has come from a single investigator, raising questions about the generalizability of findings. Well-designed prospective controlled clinical studies are needed to ascertain the value of this device in patients with neuromuscular Ventilatory problems. Motivation to perform any airway clearance technique is key to maintaining pulmonary function. An increase in sputum production, while not necessarily an indicator of improved pulmonary function, motivates most patients to continue with their physiotherapy treatment. The ease in which the therapy can be performed by a particular patient is another important consideration. Most adolescent and adult patients who need chest physiotherapy are able to carry out their treatment independently with one of the above methods and using gravity assisted positions and breathing exercises. PEP and the Flutter device are well accepted by children. Long-term comparison of these methods with large groups of patients including the selection of appropriate outcome measures, are needed for further evaluation of the potential success of various methods of airway clearance. Application to products: Unless indicated otherwise above, this policy applies to all fully insured Aetna U.S. Healthcare HMO, POS and PPO plans and to all other plans, unless a specific limitation or exception exists. For self -- funded plans, consult individual plan sponsor benefit descriptions. If there is a discrepancy between this policy and a self -- funded customer's plan of benefits, the provisions of the benefits plan will govern. With respect to fully insured plans and self -- funded non - ERISA (e.g., government, school boards, church) plans, applicable state mandates will take precedence over either. Unless otherwise specifically excluded, Federal mandates will apply to all plans. With respect to Medicare and Medicaid members, this policy will apply unless Medicare and Medicaid policies extend coverage beyond this Coverage Policy Bulletin. HCFA’s Coverage Issues Manual can be found on the following website: http://www.aetna.com/sharedsvcs/Redirect?d=std&t=/exit_disclaimer/external\ _link.html&u=http://www.hcfa.gov/pubforms/06_cim/ci00.htmhttp://www.hcfa.gov/pubforms/06_cim/ci00.htm Place of service: Home care, outpatient Click Here: http://institute.bidmc.harvard.edu/clinicalskills/clinSkills_Top.asp Becki YOUR FAVORITE LilGooberGirl YOUNGLUNG ONLINE SUPPORT www.geocities.com/younglungz YOUNGLUNG EMAIL SUPPORT LIST www.topica.com/lists/younglung Quote Link to comment Share on other sites More sharing options...
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