1. Hill-Rom Respiratory Care Lung and Airway Clearance Therapies Hill-Rom Services PTE Ltd. All rights Reserved - Vinay Joshi

2. Agenda AWC stages & overview AWC therapy devices landscape High frequency chest wall oscillation therapy The Vest therapy device overview Lung & Airway Clearance (AWC) Therapies Overview

3. Airway Clearance The entire respiratory system is lined with cells that secrete mucus. Airway mucus is a complex substance that forms a protective barrier lining the respiratory tract. Bacteria and other airborne particles become trapped in this sticky mucus and then swept upwards and outwards. Normal airway clearance is accomplished by two important mechanisms: The mucociliary clearance (MCC) system Ciliated cell: 200 cilia per cell Ciliary beat frequency – 12-22 hz,Mucus moves upward 1-3 mm/sec The ability to cough – upper airway Respiratory health depends on consistent clearance of airway secretions. Cilia move together in coordinated fashion to move mucus up airways

4. Impaired Airway Clearance Airway obstruction Mucus plugging Atelectasis Impaired gas exchange Infection Inflammation Mucus secretion and mucus clearance are not in balance in Impaired airway clearance Ineffective Ciliary Clearance: Damaged or poorly performing cilia Cystic fibrosis Primary ciliary dyskinesia Kartagener syndrome Status post heart-lung or lung transplantation Smoking or exposure to second-hand smoke Excessive or Abnormal Mucus Production : Large quantities of mucus, or mucus with altered physical properties Cystic fibrosis Bronchiectasis Asthma Chronic obstructive pulmonary disease (COPD), emphysema, chronic bronchitis Mechanical ventilation

5. Vicious Cycle of Respiratory Impairment Inflammatory response activated Mucus production Pulmonary defenses ineffective Pulmonary infection More mucus production Airway inflammation Mucus plugging General health/age Chronic/Systemic disease Recent respiratory infection Smoking history Trauma Immobility Relating to surgical procedures Factors Affecting Airway Clearance

6. Preparation Mobilization Evacuation Evaluation Nebulizers/ pharmaceuticals Humidification High Frequency Chest Wall Oscillation (The Vest®) Oscillatory Positive Expiratory Pressure (PEP) Intrapulmonary Percussive Ventilation (IPV ® ) Manual techniques CPT / Autogenic drainage Active Cycle of Breathing Technique Self Managed/ Cough Cough Assist™ Suction Stages of Airway Clearance Therapy mobilize evacuate

7. Introduction - Mucus Rheology http://www.youtube.com/watch?v=f2XQ97XHjVw http://www.youtube.com/watch?v=S5SGiwS5L6I At the macroscopic level, mucus is a non-Newtonian, thixotropic gel distinguished from classical solids and liquids by its response to shear stress. Under low shear, mucus behaves like an elastic solid and regains shape over time; under high shear, mucus behaves like a viscous liquid and eventually deforms irreversibly Mucus tend to get more fluid when exposed to shear forces

8. AWC Therapy Devices Landscape

9. Hand-Held Percussors Palm Cups ® Smith Medical ASD, Inc. G5 ® Flimm-Fighter General Physiotherapy, Inc. Types Manual Electronic Pneumatic Works by Loosening the mucus Changing Rheology of mucus Creating airflow Operates on one area at time Needs Caregiver support

10. Bed Systems with Pulmonary Therapies Features to support ventilator-associated complication protocols –Digital HOB angle indicator and alarm –Continuous lateral rotation therapy (CLRT) Pulmonary Surface (Powered Air) Pulmonary surface (powered air) –Helps prevent ventilator-associated complications when used with CLRT –Percussion and Vibration

11. Flutter ® Axcan Pharma™ US, Inc. acapella ® Vibratory PEP The vibrations during forceful exhale through device Loosens the mucus Changes Rheology of mucus Quake ® Thayer Medical Lung Flute ® Medical Acoustics inc Oscillatory PEPTherapies

12. Intrapulmonary Percussive Ventilation (IPV®) IPV1C ® -F00001-CPercussionaire Metaneb 4 – Hill-Rom The positive pressure oscillations through airway during inhale and exhale Loosens the mucus Changes Rheology of mucus Creates bursts of flow to move mucus up, uses collateral airways

13. HFCWO works on lower airways and lung areas to move the secretions to upper airways which can be then coughed out. HFCWO mobilizes the mucus by  changing the non Newtonian rheology of mucus to liquify it  Use collateral airway in lower lungs and alveoli to go behind the mucus plugs and push mucus up with airflow  Expiratory flow bias helps move mucus up from the peripheral lower airways to the upper airways for clearing through coughing, suctioning etc High Frequency Chest Wall Oscillations Therapy

14. The Vest Inflatable garment connected by hoses to an air-pulse generator. The garment rapidly inflates and deflates, compressing and releasing the chest wall.Process called high-frequency chest wall oscillation (HFCWO)

15. The Vest - HFCWO Flow Rate During Oscillation Cycle TypeFlow RateRatio Relaxed Breathing120 mL/sec.1x CPT480 mL/sec.4x Flutter®480 mL/sec.4x HFCWO1943 mL/sec.16x Cough3429 mL/sec.29x

16.  Originally developed for Cystic Fibrosis patients where 65% have used The Vest Airway Clearance System  The most researched airway clearance technique with 90 studies conducted on The Vest Airway Clearance System  Studies have demonstrated:  Safety  Cost savings  Clinical efficacy  Improved compliance  Acceptance by both healthcare teams and patients History, clinical studies and evidence Please reach out for reference of studies, white papers and other literature – vinay.joshi@hill-rom.com vinay.joshi@hill-rom.com or visithttp://www.thevest.com/physicians/http://w.thevest.com/physicians/

17. Mini coughs loosens and mobilizes mucus Thins mucus Aerosolised medications can be delivered Technique independent Doesn’t require patient huge patient effort No special positioning required Improvement in short term and longer term pulmonary function Provides consistent, quality therapy Summary of Vest HFCWO

18. Considerations for Selecting an Airway Clearance Modality Cognitive limitations – Age / mental status – Sedation Physical ability – Coordination / strength – Shortness of breath / fatigue – Mechanical Ventilation / Artificial Airways Promote improved compliance / adherence when: – Effective, without side effects – Comfortable – Time efficient – Adaptable with illness – Can be used in any setting – Easy to teach, learn and use!

19. appendix