Devices and Delivery Part II

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Devices and DeliveryPart II
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GVT Asthma COPD
Helium
BACKGROUND

• In 1868, helium was first discovered during a
  solar eclipse.
• In 1895, Ramsay isolates helium from the mineral
  cleavite.
• In 1923, Cooke realized that helium had a
  solubility coefficient half that of nitrogen and
  twice the diffusibility.
• In 1926, Sayers and Yant demonstrated that
  animals could be decompressed in one third the
  time, down from a pressure of 10 atmospheres
  using helium oxygen mixtures as opposed to using
  nitrogen oxygen mixtures.
• In 1935, Barach publishes an article on the use
  of helium in the treatment of asthma and upper
  airway obstructions.

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GVT Asthma COPD
Helium
PROPERTIES

• Helium is an inert colorless, odorless gas gas
  with no direct pharmacological or biological
  effects. The benefit of helium lies in the
  difference in its density as compared to other
  gases. The density of helium is one seventh that
  of air. Helium has the lowest density of any gas
  except hydrogen and, unlike hydrogen, is
  nonflammable. Equally important, carbon dioxide
  diffuses through helium four to five times faster
  than air.

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GVT Asthma COPD
Helium
SOURCES

• Non-renewable natural resource
• Comes from natural gas wells
• Majority comes from Amarillo, Texas
• Other well sites include Saskatchewan and areas
  near the Dead Sea
• Present in the atmosphere at approximately 1
  part in 200,000

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Helium Oxygen
DENSITY CONSIDERATIONS

• Oxygen at a 100 concentration has a density of
  1.43 g/L
• Helium at a 100 concentration has a density of
  0.18 g/L
• Helium oxygen at an 80/20 mixture has a
  density of 0.43 g/L
• Thus, an 80/20 helium oxygen mixture is 1.8
  times less dense than 100 oxygen

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Helium Oxygen
CLINICAL BENEFITS
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Helium Oxygen
WOLFSON, J PEDIATRICS, 1984

• Because heliox is less dense than air, the
  resulting decrease in the density of the
  carrier gas and decreased resistance to gas
  flow may result in an increase in bulk gas flow,
  oxygen flow, and decreased work of breathing.

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Helium Oxygen
INDICATIONS

• Acute asthma
• Treat refractory croup
• Bronchiolitis - RSV (Respiratory Syncytial
  Virus)
• Treat postextubation stridor
• Vocal cord dysfunction
• Upper airway obstruction
• Ventilatory support for obstructive defects

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Helium Oxygen
AEROSOL THERAPY
What is an Aerosol?

• Particle Deposition
• Very large in size are filtered in nose
• 100 microns
• Large - in throat
• 10 - 20 microns
• Medium - in small airways
• 2 - 5 microns
• Small - in alveoli
• 1 - 3 microns

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Helium Oxygen
AEROSOL THERAPY

• Aerosol Density and Deposition
• Density is mass / volume
• Typical units are milligrams per liter (mg/L)

• Factors that Influence Deposition
• Inertial Impaction
• Ability to make the turn
• Gravity
• Particle Characteristic
• Shape, charge, hygroscopic properties
• Breathing Pattern
• Normal slow breathing with occasional
  breath-hold

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Helium Oxygen
AEROSOL THERAPY
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Helium Oxygen
AEROSOL THERAPY
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Helium Oxygen
AEROSOL THERAPY

• Types of Nebulizers
• Small Volume Nebulizers
• Large Volume or Continuous Nebulizers
• Ultrasonic
• Metered Dose Inhalers
• Vibrating Mesh Nebulizers
• Micro Nebulizers

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Helium Oxygen
AEROSOL THERAPY

• Volume Output
• Amount of liquid nebulized into the air per time
• Normal breathing treatment with small volume
  nebulizers (SVN) last approximately ten minutes
• Need to put in at least 3 mL of fluid into the
  nebulizer
• Large Volume Nebulizers can last several hours
• Can use from 9 to 200 mL of fluid within the
  nebulizer (therapist does the calculations)

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Helium Oxygen
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Helium Oxygen
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Helium Oxygen
AEROSOL THERAPY

• Ultrasonic Nebulization
• Introduced in 1960s
• Uses piezo-electric effect
• crystal that converts electricity to sound waves
  that results in a real fine aerosol mist
• Rarely used in hospitals today
• not proven superior to SVNs
• Is more popular as a home / portable unit

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Helium Oxygen

• Ultrasonic Nebulizer

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Helium Oxygen
AEROSOL THERAPY

• Metered Dose Inhaler (MDI)
• Pressurized canister
• Steps for use
• Assemble apparatus
• Shake
• Exhale
• Place holding chamber in mouth
• Activate canister
• Inhale slowly and hold breath for 5 to 10 seconds

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Helium Oxygen

• Metered Dose Inhaler

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• Metered Dose Inhaler Spacers

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• Metered Dose Inhaler Spacers

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The Aeroneb Professional Nebulizer System is the
first major technological advance in 20 years
specifically designed for patients requiring
aerosolized therapy while on mechanical
ventilation. It improves drug delivery efficiency
and offers the potential to reduce drug and
personnel costs associated with in-patient
treatment while maintaining the integrity of
ventilator-dependent care.
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KASS, CHEST, 1999

• 23 adult pts with asthma in ED setting
• Prospective, randomized, controlled trial
• He-O2 70/30 vs. N2-O2 70/30

Both groups received methylprednisolone 125 mg
IV inhaled albuterol 2.5 mg nebs x 2
After 20 minutes of therapy Heliox group PEF ?
58.4 N2-O2 group PEF ? 10.1
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KRESS, AJRCCM, 2002

• Adult pts in ED for asthma (n 45)
• Randomized Heliox 80/20 vs. 100 Oxygen

3 consecutive albuterol neb treatments (0.5 cc
each) given over 90 min.
Increase in FEV1, control vs. heliox 1st Tx
14.6 vs. 32.4 2nd Tx 22.7 vs. 51.5
3rd Tx 26.7 vs. 65.1
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CONSIDERATIONS

• Although heliox may be a valuable tool in the
  treatment of airway pulmonary problems, it has
  no inherent therapeutic effects.
• Helium conducts heat much more readily than does
  nitrogen. (Heat loss? - humidify and warm)
• It should be used only as a temporary solution
  to allow time for
• The effect of therapeutic agents to take hold
• the natural resolution of the disease process or
  condition to occur
• To buy time for adequate planning in dealing with
  difficult airway problems

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CONSIDERATIONS

• Pure 100 helium should never be used.
• 70/30 helium oxygen mixtures are also
  popular.
• Effort should be made to deliver the maximum
  amount of helium while maintaining the patients
  oxygen saturation level above 90.
• If the patient requires greater than 40 oxygen,
  heliox therapy will most likely not be effective.

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MODES OF DELIVERY

• Non-rebreather mask
• Non-rebreather mask with a small volume nebulizer
• Large volume nebulizer
• Conventional mechanical ventilation
• High frequency oscillator (HFOV)
• FDA clearance
• High flow nasal cannula
• Micro pump nebulizer
• Non-invaisive pressure device
• Mechanical ventilator

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AVEA Comprehensive Ventilator

• AVEA is the first generation of integrated life
  support systems meeting the needs of all
  neonatal, pediatric, and adult patients.
• AVEA is the first safe, reliable solution for
  Heliox delivery. AVEA's internal blending system
  automatically compensates for the gas mixture
  providing unwavering accuracy in all delivered
  and monitored parameters as well as graphic data.
  
• AVEA streamlines Heliox delivery. Patients
  suffering from COPD and Asthma have benefited
  clinically from Heliox therapy.
• AVEA has the ability to deliver non-invasive
  ventilation with Heliox to adult and pediatric
  patients. Clinical data from peer-reviewed
  journals suggests non-invasive ventilation can
  potentially reduce length of stay and
  complications.