3. Aeromedical evacuation

4. Hoist Rescue

5. Sling single?

6. Double sling?

7. Stretcher?

8. Rescue basket?

9. Respiratory Function in Hoist Rescue:
Comparing
Slings, Stretcher, and Rescue Basket
David Murphy , Alan Garner , and Rod Bishop
From CareFlight NSW, Northmead, NSW, Australia.
Aviation, Space, and Environmental Medicine x Vol. 82, No. 2 x February 2011
CareFlight NSW, Northmead, NSW, Australia

10. INTRODUCTION

11. INTRODUCTION
B) double sling A) single sling

12. INTRODUCTION
D) rescue basket C) stretcher

13. INTRODUCTION

14. INTRODUCTION

15. So what happens? INTRODUCTION
Suspention trauma and harness-hang syndrome
∗ General feelings of unease
∗ Dizzy, sweaty and other signs of shock
∗ Increased pulse and breathing rates
∗ Then a sudden drop in pulse & BP
∗ Instant loss of consciousness
∗ If not rescued, death is certain
∗ From suffocation due to a closed airway, or
from lack of blood flow and oxygen to the
brain.

16. INTRODUCTION
Suspention trauma and harness-hang syndrome

17. INTRODUCTION

18. INTRODUCTION

19. INTRODUCTION

20. INTRODUCTION

21. INTRODUCTION
Sever Asthma
When is a severe acute episode
happening?
• Limited ability to speak
• Pulsus paradoxus > 25mmHg
• Pulse >110/min
• RR >25-30/min
• Flow rates <50% predicted
• O2 saturation <91-92%
• Some consider flow rates < 35% predicted
to be life-threatening

26. Stepwise approach ( children)
classificati mild Mild Moderate Severe
on Intermitte persistent persistent persistent
nt
Minor < 1/week 1-3 /week 4-5/week Continuou
symptoms s
exacerbati < 1/month 1 /month 2-3/month > 4
on/ /month
nocturnal
PEF >80% >80% 60-80% < 60%
between
attacks
Step 1 Step 2 Step 3 Step 4

27. Stepwise approach ( adult)
classificati mild Mild Moderate Severe
on Intermitte persistent persistent persistent
nt
Minor < 2 /week 2-3 /week 4-5 /week Continuou
symptoms s
exacerbati <2 2-3 4-5 >5
on/ /month /month /month /month
nocturnal
PEF >80% >80% 60-80% < 60%
between
attacks
Step 1 Step 2 Step 3 Step 4

28. Asthma classification

29. INTRODUCTION

30. INTRODUCTION
>
Rescue Basket (RB) Stretcher

31. INTRODUCTION
H0 & H1 thesis
H1:Use of the RB would not be associated with impairment of spirometry in healthy
volunteers
H0:Use of the Stretcher would not be associated with impairment of spirometry in
healthy volunteers

32. METHODS

33. Winch
simulator

34. METHODS
Randomized ,Controlled cross-over study

35. Hypothesis Testing: Case-Crossover Studies
Randomized ,Controlled cross-over
study
∗ Study of “triggers” within an individual
∗ ”Case" and "control" component, but information of both
components will come from the same individual
∗ ”Case component" = hazard period which is the time period
right before the disease or event onset
∗ ”Control component" = control period which is a specified time
interval other than the hazard period

36. METHODS
Randomized ,Controlled cross-over
study

37. METHODS

38. Table of Random Numbers
Sequence - randomization
542-04-#38

39. METHODS

40. METHODS

41. METHODS
EasyOne Diagnostic Spirometer

42. Pulmonary Function
Testing

43. Perform test

44. Types of Spirometers
∗ Bellows spirometers:
Measure volume; mainly in lung function units
∗ Electronic desk top spirometers:
Measure flow and volume with real time display
∗ Small hand-held spirometers:
Inexpensive and quick to use but no print out

45. Volume Measuring Spirometer

46. Flow Measuring Spirometer

47. Desktop Electronic Spirometers

48. Small Hand-held Spirometers

49. Actual PFT Performance Technique
∗ Prepare the equipment – find a nurse who knows (or is
that nose?) what to do.
∗ Patient should be seated with nose clip in place.
∗ The patient needs to practice the exercise before actually
performing the test. Have the patient breath in and out
deeply several times.
∗ Ask the patient to breath in as deeply as they can.

50. Actual PFT Performance Technique
∗ The patient should place their mouth completely over
the mouthpiece, not inside it.
∗ Ask the patient to blow out as fast and as quick as they
can for at least six seconds. Enthusiatically coach the
patient – jump, shout, get down, hoot and holler…
“Blow, blow, come on, blow more, you can do it!”

51. Actual PFT Performance Technique
∗ Once the patient has blown out as much as they can,
ask them to then inhale as deeply as they can.
∗ Repeat the whole test three times. The goal is to get
a reproducible result that is consistent.
∗ You may need to repeat the test more than three
times in order to obtain an internally valid test.

52. Difinitions &
Considerations

53. Lung Volumes and Capacities
∗ There are four basic lung volumes:
∗ Inspiratory reserve volume (IRV)
∗ Tidal volume (TV)
∗ Expiratory reserve volume (ERV)
∗ Residual volume (RV)
∗ In various combinations, these lung volumes then
form lung capacities.
∗ E.g., Vital capacity = IRV + TV + ERV

55. Lung Volumes

56. Normal Spirometry

57. Obstructive Pattern
■ Decreased FEV1
■ Decreased FVC
■ Decreased FEV1/FVC
- <70% predicted
■ FEV1 used to follow severity in COPD

58. Obstructive Lung Disease — Differential
Diagnosis
 Asthma
 COPD
- chronic bronchitis
- emphysema
 Bronchiectasis
 Bronchiolitis
 Upper airway obstruction

59. Restrictive Pattern
 Decreased FEV1
 Decreased FVC
 FEV1/FVC normal or increased

60. Restrictive Lung Disease —Differential
Diagnosis
 Pleural
 Parenchymal
 Chest wall
 Neuromuscular

61. Spirometry Patterns

62. Indications for
Pulmonary Function Testing
∗ Patients 45 years old and older who have ever smoked.
∗ Patients with prolonged or excessive cough or sputum
production.
∗ Patients with a history of exposure to lung irritants.

63. Indications for
Pulmonary Function Testing
∗ Detecting pulmonary disease
∗ Pulmonary symptoms – chest pain, orthopnea, cough,
phlegm production, dyspnea, wheezing
∗ Physical findings – Chest wall problems, cyanosis,
clubbing, decreased breath sounds
∗ Abnormal labs/x-rays – ABG, Chest X-Ray

64. Indications for
Pulmonary Function Testing
∗ Assessing disease severity and progression
∗ Pulmonary disease – COPD, Cystic fibrosis, Interstitial lung
disease, Sarcoidosis
∗ Cardiac disease – CHF, Congenital heart disease, Pulmonary
hypertension
∗ Neuromuscular disease – Amyotrophic lateral sclerosis, Guillain-
Barre syndrome, Multiple sclerosis, Myasthenia gravis

65. Indications for
Pulmonary Function Testing
∗ Pre-operative risk stratification
∗ Thoracic surgery
∗ Cardiac surgery
∗ Organ transplantation
∗ General surgical procedures
∗ Evaluating disability and impairment

66. Contraindications for PFT
Relative contraindications for spirometry include hemoptysis of
unknown origin, pneumothorax, unstable angina pectoris,
recent myocardial infarction, thoracic aneurysms, abdominal
aneurysms, cerebral aneurysms, recent eye surgery (increased
intraocular pressure during forced expiration), recent abdominal
or thoracic surgical procedures, and patients with a history of
syncope associated with forced exhalation.

67. Normal Values
∗ FVC is the total amount of air a person can exhale,
usually measured in six seconds.
∗ 80 – 120% of predicted is a normal value
∗ 70 – 80% demonstrates mild reduction/restriction
∗ 50 – 70% demonstrates moderate reduction
∗ <50% demonstrates severe reduction
∗ FEV1 is the amount of air a person can exhale in one
second.
∗ 80 – 120% of predicted is a normal value

68. Normal Values
∗ FEV1/FVC ratio is the percentage of FVC that can be
expired in one second.
∗ 75 – 80% is normal
∗ 60 – 80% demonstrates mild obstruction
∗ 50 – 60% demonstrates moderate obstruction
∗ <50% demonstrates severe obstruction

69. Normal Values
∗ FEF25-75 reflects small airway function
∗ >80% is normal
∗ 60 – 80% reflects mild obstruction in the small airways
∗ 40 – 60% reflects moderate obstruction
∗ <40% reflects severe obstruction

70. Spirometry Interpretation: So
what constitutes normal?
∗ Normal values vary and depend on:
∗ Height
∗ Age
∗ Gender
∗ Ethnicity

71. PFT Interpretation

72. PFT Interpretation
∗ Three steps in interpretation
∗ Is the test valid?
∗ Interpret the test
∗ Classify severity of disease if present

73. Validity
∗ The test is valid is you have good patient effort and
the three tests performed are internally consistent.
∗ You may notice a learning curve in that the latter tests
are better performed than the former.
∗ Make sure that the tests are maximal effort. You
need to be really aggressive in coaching your patient.

74. Acceptability Criteria
1 - good start of test : sharp take off
2- Meet end-of-test criteria
3- free from artifacts:
-Cough or glottis closure during the first second of exhalation
-Variable effort , submaximal effort
-Leak
-Obstructed mouthpiece
-Have a satisfactory exhalation 6 s of exhalation

75. Reproducibility Criteria
After 3 acceptable spirograms been obtained
 Are the two largest FVC within 150ml of each other?
 Are the two largest FEV1 within 150ml of each other?
If both of these criteria are met, the test session may be concluded.
If both of these criteria are not met, continue testing until Both of the
criteria are met with analysis of additional acceptable spirograms; OR
a total of eight tests have been performed

76. Interpretation of Spirometry
Step 1. Look at the Flow-Volume loop
Step 2. Look at the FEV1 (Nl ≥ 80% predicted).
Step 3. Look at FVC (Nl ≥ 80%).
Step 4. Look at FEV1/FVC ratio (Nl≥ 75%).
Step 5. Look at FEF25-75% (wide normal range)

77. Normal Values
∗ FVC is the total amount of air a person can exhale,
usually measured in six seconds.
∗ 80 – 120% of predicted is a normal value
∗ 70 – 80% demonstrates mild reduction/restriction
∗ 50 – 70% demonstrates moderate reduction
∗ <50% demonstrates severe reduction
∗ FEV1 is the amount of air a person can exhale in one
second.
∗ 80 – 120% of predicted is a normal value

78. Normal Values
∗ FEV1/FVC ratio is the percentage of FVC that can be
expired in one second.
∗ 75 – 80% is normal
∗ 60 – 80% demonstrates mild obstruction
∗ 50 – 60% demonstrates moderate obstruction
∗ <50% demonstrates severe obstruction

79. Normal Values
∗ FEF25-75 reflects small airway function
∗ >80% is normal
∗ 60 – 80% reflects mild obstruction in the small airways
∗ 40 – 60% reflects moderate obstruction
∗ <40% reflects severe obstruction

80. PFT Interpretation
Assess FVC, FEV1, and FEV1/FVC ratio.
FVC and FEV1 normal, with a normal FEV1/FVC ratio: Normal Test
FVC low, FEV1 low or normal, and a normal to high FEV1/FVC ratio:--
Restrictive lung disease
FVC low or normal, FEV1 low, and a low FEV1/FVC ratio:
Obstructive lung disease

81. Measurements Obtained from the FVC
Curve
∗ FEV1---the volume exhaled during the first second of the
FVC maneuver
∗ FEF 25-75%---the mean expiratory flow during the middle
half of the FVC maneuver; reflects flow through the small
(<2 mm in diameter) airways
∗ FEV1/FVC---the ratio of FEV1 to FVC X 100 (expressed as a
percent); an important value because a reduction of this
ratio from expected values is specific for obstructive
rather than restrictive diseases

82. Spirometry Interpretation:
Obstructive vs. Restrictive Defect
∗ Obstructive Disorders ∗ Restrictive Disorders
∗ FVC nl or↓ ∗ FVC ↓
∗ FEV1 ↓ ∗ FEV1 ↓
∗ FEF25-75% ↓ ∗ FEF 25-75% nl to ↓
∗ FEV1/FVC ↓ ∗ FEV1/FVC nl to ↑
∗ TLC nl or ↑ ∗ TLC ↓

83. Spirometry Interpretation: What
do the numbers mean?
∗ FVC FEV1
∗ Interpretation of % predicted: Interpretation of % predicted:
∗ 80-120% Normal ∗ >75% Normal
∗ 70-79% Mild reduction ∗ 60%-75% Mild obstruction
∗ 50%-69% Moderate reduction ∗ 50-59% Moderate obstruction
∗ <50% Severe reduction ∗ <49% Severe obstruction
∗ <25 y.o. add 5% and >60 y.o.
subtract 5

84. Actual Predicted % Predicted
FVC 4.0 4.5 88
FEV1 3.4 4.2 89
FEV1/FVC 85 82 112
FEF25-75
Normal

85. Actual Predicted % Predicted
FVC 2.0 4.0 50
FEV1 1.8 3.7 47
FEV1/FVC 90 82 112
FEF25-75
Restrictive Pattern

86. Actual Predicted % Predicted
FVC 4.0 4.5 88
FEV1 2.4 4.2 58
FEV1/FVC 60 82 76
FEF25-75 2.2 4.4 50
Obstructive Pattern

87. Acceptable and Unacceptable
Spirograms (from ATS, 1994)

88. PFTs

89. Normal vs. Obstructive vs. Restrictive

90. Variable Effort

91. Early Glottic Closure

92. Cough

93. Flow-Volume Loops

94. Flow-Volume Loops

95. Special Techniques
∗ Beta Agonist Challenge
∗ Methacholine Challenge
∗ DLCO

96. Beta Agonist Challenge
∗ Perform this when there is a suspicion that the
obstructive defect may be reversible –> asthma.
∗ Give the patient a beta agonist treatment (two puffs
of an albuterol MDI or an albuterol nebulizer) and
repeat the PFTs several minutes later. If you notice a
12% or more increase in FEV1, then you have diagnosed
reversible airway disease/asthma.

97. Methacholine Challenge
∗ If you have a suspicion that the patient might have Exercise-
induced bronchospasm (EIB), then refer them to a pulmonary
lab where they can do provocative testing with methacholine.
∗ If the patient has a decrease in their FEV1/FVC ratio with the
inhalation of methacholine, then you have diagnosed EIB.
∗ Pretreat before exercise with albuterol or cromolyn.

98. Diffuse capacity of carbon monoxide in
the lung DLCO
∗ After performing the standard PFTs, the patient then inhales
trace amounts of carbon monoxide.
∗ CO traverses the alveolar capillary beds much more readily than
CO2 or O2.
∗ As such, most of the CO inhaled should be absorbed.
∗ When it is not, this suggests pulmonary scarring consistent with
pulmonary fibrosis. Search for a cause.

99. Diffusing Capacity
 Decreased DLCO  Increased DLCO
(>120-140% predicted)
(<80% predicted)
 Asthma (or normal)
 Obstructive lung disease
 Pulmonary hemorrhage
 Parenchymal disease
 Polycythemia
 Pulmonary vascular disease
 Left to right shunt
 Anemia

101. paired T test
The paired t-test will show whether the
differences observed in the 2 measures will be
found reliably in repeated samples.

102. ANOVA:One way
If we have data measured at the interval level, we
can compare two or more population groups in
terms of their population means using a
technique called analysis of variance, or ANOVA.

103. Honestly significant difference test (HSD)
When you do multiple significance tests, the
chance of finding a "significant" difference just
by chance increases. Tukey´s HSD test is one of
several methods of ensuring that the chance of
finding a significant difference in any comparison
(under a null model) is maintained at the alpha
level of the test.

104. RESULTS

111. DISCUSSION

112. DISCUSSION

113. DISCUSSION

114. DISCUSSION

115. DISCUSSION

116. DISCUSSION

117. DISCUSSION

118. DISCUSSION

119. DISCUSSION
Air Turbulance

120. DISCUSSION
Major sources of noise generated by a helicopter

121. DISCUSSION

122. DISCUSSION
Static Spirometry

123. DISCUSSION
Dynamic Spirometry

124. DISCUSSION

125. DISCUSSION
Body Plethysmography

126. DISCUSSION
Body Plethysmography

127. DISCUSSION
helium dilution

128. DISCUSSION

130. DISCUSSION

131. DISCUSSION

134. THANKS FOR
YOUR
ATTENTION
134