Transcript Bronchial Hygiene: Why So Important?

Bronchial Hygiene & High Frequency
Devices: Why So Important?
David Grooms MSHS, RRT
Sentara Norfolk General Hospital
Disclosures
Today’s lecture is sponsored by Hill-Rom
Consultant Honorariums:
•
•
Hamilton Medical
Hill-Rom
Speakers List:
•
•
Hamilton Medical
Hill-Rom
Sentara Healthcare, Norfolk, VA
Sentara Norfolk General- Norfolk, VA
Sentara Leigh- Norfolk
Sentara Princess Anne- VA Beach
Sentara Virginia Beach General- VA Beach
Sentara Obici- Suffolk, VA
Sentara Careplex- Hampton, VA
Sentara WRCH- Williamsburg, VA
Sentara NMVC- Potomac, VA
Sentara Rockingham Memorial- Harrisonburg, VA
Sentara Martha Jefferson- Charlottesville, VA
Sentara HallifaxSentara Albemarle-
We have come a long way with
understanding Breathing!
Sentara Clinical 3
Recent review of CPT & pnuemonia 2013
Recent review of CPT & pnuemonia 2014
Six RCTs (434 participants)
Four types of chest physiotherapy:
1. Conventional chest physiotherapy
2. Osteopathic manipulative treatment (which
includes paraspinal inhibition, rib raising and
myofascial release)
3. active cycle of breathing techniques:
1.
2.
3.
4.
Active breathing control
Thoracic expansion exercises
Forced expiration techniques
Positive expiratory pressure
Recent review for CPT & Pneumonia
“Limited evidence indicates that positive expiratory
pressure (versus no physiotherapy) and osteopathic
manipulative treatment (versus placebo therapy) can
slightly reduce the duration of hospital stay (by 2.02
and 1.4 days, respectively)
The “Why” of it…
•We
are part of this
business:
•We are a stake holder
•We are part owner
•We directly effect the
outcomes of this hospital.
The “Clinical Why” of it…
•We
spend too much money
taking care of patients.
•We are paid on volume of
patient care provided, not
quality of patient care
•Penalization for sub optimal
patient care and results is
coming!!!
Balancing of Expense Vs.
Reimbursement
Loss of employment
$$
Reimbursement
Revenue
Profit
Quality of Care
Jeopardized
Staff analysis
Wages
Service not needed
Justified Services
Expenses
Time
What we want it to look like tomorrow
Managing Expenses with improved quality of care
$$
Reimbursement
Revenue
Profit
Expenses
Time
Quality of Pt. Care
How Hospitals Get Paid (101)
•Payment
Per Procedure: Fee-for-service
•Payment Per Episode of Hospitalization: DiagnosisRelated Group (DRG)
•Payment Per Day: Per Diem
•Payment Per Patient: Capitation
•Payment per Institution: Global Budget
Payment Per Procedure: Fee for service
•Patient
comes to hospitals and gets series of test.
•Receives bill for test at the hospital cost.
•Insurance company negotiates price reduction.
•Example: CT scan which normally cost $1,000
would be given at a reduced rate of $700 to a
patient who is covered under a specific insurance.
Diagnosis-Related Groups (DRG)
•A
strategy used by Medicare.
•Patients diagnosis tells the hospital how much money
the insurance company will give to them.
•Example: COPD diagnosis= $100,000 to treat.
•Hospital spends $80,000 to treat efficiently, hospital
makes $20,000
•Hospital spends $120,000 to treat, hospital loses
$20,000.
•Hospitals have incentive to discharge patients
efficiently, since their pay is not going to increase with
length of stay, unless of course another DRG.
Hypothetical Example- COPD DRG=$100,000
160000
Daily Expense
Initial Revenue
140000
Total Expense
120000
Total Revenue
100000
80000
60000
40000
20000
0
1
-20000
-40000
-60000
2
3
4
5
6
7
8
To Protocolize or not to Protocolize?
Historical- Physician Directed Practice
• Intervention- RT Protocol directed practice
•Outcomes:
•
Treatment Allocation
• Cost
• Hospital and ICU outcome.
•
Treatment Allocations
Stoller et al. Chest 110(2), 1998
Reductions in Patient Days, LOS &
Treatments Cost Association
Shapiro et al. Chest 1988
Understanding Mucus
MUCUS IN THE RESPIRATORY TRACT
Contains H2O, Proteins, Mucins,
Antibodies, and Antiseptics and
Salts.
• Carbohydrate coating gives the
mucin molecules a large ability to
absorb water.
•
Mucociliary Clearance System


Self clearing mechanism
Designed to move bacteria,
dust from inhaled air, and
dead cells from the deep
lung to the larynx & mouth
for expectoration.
Effects of Cigarette Smoke on
Mucociliary Development & Size
Reduction in ciliary development
Reduction in ciliary size
Tamashiro, et al. Braz J Otorrhinology. 2009;75(6):903-907.
A closer look at how mucus is
thought to be dislodged……..
1
Insp
2
3
4
Exp
Mechanism of Action for High
Frequency Devices
OCI= Oscillatory Clearance Index
f= Oscillatory frequency (Hz)
TI=duration of outward
inspiratory airway wall
displacement
TE=duration of inward expiratiory
airway wall displacement
VE-max= Maximum exp. Flow
VI-max= Max insp. flow
Popular High Frequency Handheld
Devices
Flutter Valve
Acapella
RC-Cornet
Aerobika