Patent Application
20090277447
This invention relates generally to the field of cardiopulmonary resuscitation and, in particular, to techniques to increase circulation when performing cardiopulmonary resuscitation (“CPR”).
Despite current methods of CPR most people die after cardiac arrest. One of the major reasons is that blood flow to the heart and brain is very poor with traditional manual closed chest CPR. Greater circulation of blood during CPR would result in improved outcomes.
CPR has traditionally been performed by repetitively compressing the chest and intermittently providing positive pressure ventilation. Each time the chest is compressed and then allowed to recoil, blood circulates to the heart and brain; and each time a breath is delivered, the lungs fill with oxygen. This approach is extremely inefficient, in part, because each positive pressure ventilation results in an increase in pressure within the thorax and a consequent reduction in venous blood flow back to the heart. In addition, each positive pressure breath increases intracranial pressure and thereby reduces cerebral blood flow.
Multiple methods may be used when performing CPR in patients in cardiac arrest. In this life-threatening situation, the heart is not capable of circulating blood, so non-invasive external means are used to assist in the circulation of blood to the vital organs, including the heart, lungs, and brain. The methods and devices that may be used to circulate blood during cardiac arrest usually include the manipulation of one or more of a patient's body parts, usually the chest, to increase the magnitude and duration of the patient's negative intrathoracic pressure. The most common methods include manual closed chest CPR, active compression/decompression (ACD) CPR, mechanical CPR with manual or automated devices that compress the chest and either allow the chest to recoil passively or actively, and devices that compress the chest wall and then function like an iron lung and actively expand the thoracic cage. Some of these approaches and devices only compress the anterior aspect of the chest, such as the sternum, while other approaches and devices compress all or part of the thorax circumferentially. Some approaches and devices also compress the thorax and abdomen in an alternating sequence. Some approaches also involve compressing the lower extremities to enhance venous blood flow back to the heart and augment arterial pressure, so that more blood goes to the brain. Other approaches also involve compressing the back while the patient is lying on his/her stomach. Some devices include the non-invasive methods and devices outlined above that are coupled with invasive devices, such as an intra-aortic balloon, and devices to simultaneously cool the patient.
Because the cardiac valves remain essentially intact during CPR, blood is pushed out of the heart into the aorta during the chest compression phase of CPR. When the chest wall recoils, blood from extrathoracic compartments (e.g., the abdomen, upper limbs, and head) enters the thorax, specifically the heart and lungs. During the chest wall recoil phase, blood fills the cardiac chambers as well as the coronary arteries, i.e., the arteries that provide blood to the heart muscle. Without the next chest compression, the blood would pool in the heart and lungs during cardiac arrest, as there is insufficient intrinsic cardiac pump activity to promote forward blood flow. Thus, chest compressions are an essential part of CPR.
Blood flows to the brain during both the chest compression and decompression phases. The amount of blood flow to the brain depends upon the gradient between forward blood flow (determined in large part by the arterial pressure) and the resistance in flow into the brain (determined in large part by the intracranial pressure).
During the compression phase of closed chest manual (standard) CPR, air is pushed out of the thorax and into the atmosphere via the trachea and airways. During the decompression phase, air passively returns back into the thorax via the same airway system. As such, respiratory gases move out of and back into the thorax. With each compression the pressure within the chest is nearly instantaneously transmitted to the heart, and also to the brain via the spinal column and vascular connections. Thus, with each external chest compression, pressure is increased in the thorax and within all of the organs in the thorax.
A variety of impeding or preventing mechanisms may be used to prevent or impede respiratory gases from flowing back into the lungs, including those described in U.S. Pat. Nos. 5,551,420; 5,692,498; 6,062,219; 5,730,122; 6,155,257; 6,234,916; 6,224,562; 6,986,349; and 7,204,251, the complete disclosures of which are herein incorporated by reference. The mechanisms may be configured to completely prevent or provide resistance to the inflow of respiratory gases into the patient while the patient inspires. In devices that completely prevent the flow of respiratory gases, the valves may be configured as pressure responsive valves that open after a threshold negative intrathoracic pressure has been reached. Such systems and devices are referred to herein collectively by the name “impedance threshold device” or “ITD”. Other examples of such ITDs are described in U.S. Pat. Nos. 6,526,973 and 6,604,523, incorporated herein by reference. However, it will be appreciated that a wide variety of devices may be used. As another example, devices may be interfaced with a person's airway to prevent respiratory gas flow to the person's lungs during a portion of an inhalation event to enhance circulation and decrease intracranial pressure, including those described in U.S. Pat. No. 7,195,012, incorporated herein by reference.
Methods and devices, such as ITDs that reduce the amount of respiratory gases inside the thorax by preventing said gases from reentering the thorax during the chest wall recoil phase, or by actively removing said gases either intermittently or continuously, result in less and less air in the thorax. Less air in the thorax makes room for more and more blood to return to the heart during the chest wall recoil phase. Application of the aforesaid methods and devices cause a reduction in intrathoracic pressures, either during the chest wall recoil phase or continuously during the chest compression and decompression phases, which results in a simultaneous decrease in intracranial pressures. As such, application of these methods and devices increases circulation to the coronary arteries during the chest wall decompression phase, and increases blood flow to the brain during the compression and decompression phases, thereby delivering more oxygen-rich blood to the brain.
The prior art has failed to take a systems-based approach that includes methods and devices that are optimized to interface with the patient's airway, provide the benefits of ITD therapy and maximize circulation to the heart and brain by compressing and decompressing the chest. Such an approach would be desirable since it may result in an overall increase in the likelihood of a positive outcome after cardiac arrest.
As previously mentioned, traditional or standard CPR also includes the delivery of a positive pressure breath periodically, in order to inflate the lungs and provide oxygen (“O2”). In addition, positive pressure ventilation provides a means to remove carbon dioxide (“CO2”) from the lungs. Since the delivery of O2 is an important aspect of CPR, periodic positive pressure ventilation traditionally needs to be delivered to inflate the lungs and provide oxygen. However, recently some harmful effects of positive pressure ventilation have been demonstrated. See, K. Lurie et al.; “Hyperventilation-induced hypotension during cardiopulmonary resuscitation,” Circulation; Apr. 27, 2004; 109(16):1960-5, incorporated herein by reference. Each time positive pressure ventilation is delivered, intrathoracic pressure rises. The rise in intrathoracic pressure results in an immediate reduction in venous blood flow back to the heart, and an immediate rise in intracranial pressures, thereby resulting in greater resistance to forward blood flow to the brain. This occurs when the chest compressions are delivered continuously or with periodic pauses for a positive pressure breath. When chest compressions are stopped in order to deliver a positive pressure breath (which is currently recommended by the American Heart Association when the airway is not secured by a ventilation tube such as an endotracheal tube), blood flow to the heart and brain nearly ceases. Without the chest compressions to serve as a pump during the period of time a positive pressure breath is delivered, there is no circulation of blood to the heart and brain.
With traditional CPR, the lungs need to be regularly inflated to provide O2 to the lungs and to support movement of blood through the pulmonary vasculature. O2 exchange is inadequate without positive pressure ventilation, especially for prolonged resuscitation efforts, and the lungs develop atelectasis or collapse, making blood flow through the lungs more difficult as the pulmonary vascular resistance becomes too high. See K. Lurie et al.; “Comparison of 10 versus 2 breaths per minute strategy during cardiopulmonary resuscitation in a porcine model of cardiac arrest,” Journal of Respiratory Care; 2008, in press, incorporated herein by reference. Thus, periodic inflation of the lungs provides O2, helps to clear CO2, and helps to reduce pulmonary vascular resistance (resistance to blood flow through the lungs) by preventing lung collapse.
However, in light of these recently discovered advances in understanding the physiology of blood flow, and the effects of positive pressure ventilation on blood flow to the heart and brain, as well the resistance to blood flow through the lungs, new methods and devices are needed that: a) obviate the need for positive pressure ventilation, b) provide a means to lower intrathoracic pressure during CPR (to augment venous blood flow back to the heart and lower intracranial pressures), and c) still provide a means to prevent lung collapse. Accordingly, the present invention provides new methods, systems and devices that optimize circulation and respiration during CPR while avoiding the harmful effects of positive pressure ventilation.
In one embodiment, the invention provides a method for performing cardiopulmonary resuscitation which comprises interfacing with a person's airway an airway system that includes at least a first lumen and a second lumen. CPR chest compressions may be repeatedly performed on the person, and simultaneously with the chest compressions, a continuous vacuum may be applied to the airway. In one embodiment, the continuous vacuum may be applied to the first lumen of the airway system. In one embodiment, the continuous vacuum may be applied for a period of time ranging from 10 seconds to the end of the CPR chest compressions. Simultaneously, an effective amount of O2 gas may be injected into the person's lungs through the second lumen at a high velocity. By applying continuous vacuum to the patient's airway and simultaneously insufflating O2 into the lungs at a high velocity sufficient to circulate O2 into the alveoli, the present invention provides significantly greater blood flow to the heart and brain during CPR, and thereby provides an improved method for resuscitation without the necessity of positive pressure ventilation.
In one embodiment, the continuous vacuum applied to the first lumen may be about −2 mmHg to about −20 mmHg. In another embodiment, the velocity of the O2-rich gas may be about 20 ft./sec. to about 1100 ft./sec. In still another embodiment, additional steps may be added wherein the continuous vacuum may be discontinued and positive or negative pressure ventilation may be supplied through the first lumen to the patient with or without the CPR chest compressions and with or without the injection of high velocity oxygen gas through the second lumen.
In one embodiment, negative intrathoracic pressure may be maintained at least in part by using an impedance threshold device that prevents respiratory gases from returning to the patient's thorax during the decompression phase of each CPR chest compression. In another embodiment, the CPR chest compressions may be performed using closed chest CPR, active compression/decompression CPR, or mechanical CPR with a manual or automated device that compresses the chest wall and either allows the chest to recoil passively or actively re-expands the thoracic cage of the patient. In another embodiment, the delivery of O2 gas and/or the application of continuous vacuum may be regulated based upon one or more physiological measurements such as airway pressure, intracranial pressure, O2 saturation, end tidal CO2, transcutaneous lactate, pH measurements, and the like.
In another embodiment, the invention provides a cardiopulmonary resuscitation system for use during the performance of CPR chest compressions on a patient. The CPR resuscitation system may comprise an airway system configured to interface with a patient's airway. The airway system includes at least a first and a second lumen, with the first lumen being configured to ventilate the patient's lungs during the CPR chest compressions. A source of oxygen gas may be coupled to the second lumen, which may be configured to inject an effective volume of oxygen gas from the source of oxygen gas into the patient's lungs at high velocity during the CPR chest compression. Means may also be provided for applying a continuous vacuum to the person's airway simultaneously with the injection of oxygen gas and the performance of CPR chest compressions, at least for a period of time ranging from 10 seconds to the end of the CPR chest compressions. In one embodiment, the continuous vacuum is applied for at least 15 seconds and in some cases for at least 30 seconds. For example, the vacuum means may comprise a source of continuous vacuum coupled with the first lumen. The airway system may further comprise at least a second lumen configured to be coupled with a source of O2, so that O2 gas may be injected at high velocity into the person's airway through the second lumen during the performance of the repeated CPR chest compressions and the application of continuous vacuum through the first lumen.
In one embodiment, the first lumen of the airway system may comprise the central lumen of a ventilation tube, e.g., an endotracheal tube or a supraglottic airway adjunct, and the second lumen may comprise one or more small diameter (e.g., about 0.025-1.0 cm) tubules or cannula positioned within the ventilator tube's central lumen. In another embodiment, the airway system may further comprise an impedance threshold device configured to prevent respiratory gases from flowing into the person's airway. In other embodiments, the resuscitation system may include a valve system configured to discontinue the application of continuous vacuum and thereafter supply positive pressure ventilation to the person' airway through the first lumen of the airway system. Such valve systems may include a fish mouth valve that is closed when continuous vacuum is being applied to the first lumen and is opened when positive pressure ventilation is applied to the first lumen. Another example of such a valve system may comprise a piston and a pair of rolling diaphragms that are movable between a first position that allows the application of continuous vacuum to the first lumen and seals off the source of positive pressure ventilation to the first lumen, and a second position that allows the application of positive pressure ventilation to the first lumen and seals off the source of continuous vacuum to the first lumen.
In one embodiment, the continuous vacuum may be regulated by one or more regulators configured to generate a negative airway pressure of between about −2 mmHg and about −20 mmHg, and, in another embodiment, a pressure gauge may be incorporated to measure airway pressures and/or intrathoracic pressure during application of the resuscitation system. In another embodiment, the resuscitation system may include a controller comprising control valves connected to a microcontroller to regulate the application of continuous vacuum and the delivery of high velocity O2 gas in one phase, and the application of positive airway pressure to the person in a second phase.
In another embodiment, the invention provides a locking supraglottic airway system comprising an airway tube having a central lumen with a proximal supraglottal section and a distal esophageal section. The system may further comprise means for applying a continuous vacuum to the central lumen; means for advancing the airway tube into a patient's airway; a first inflatable cuff positioned in the esophageal section of the airway tube and configured to seal off the esophageal area of the patient's airway when inflated; and a second inflatable cuff positioned in the supraglottal section of the airway tube and configured to seal off the laryngeal area of the patient's airway when inflated. The second cuff may comprise an extension configured to seal off the nasopharyngeal area of the patient's airway when inflated. The first and second cuffs act to maintain a negative intrathoracic pressure in the patient's airway when a vacuum is applied to the central lumen.
In one embodiment, the locking supraglottic airway system may further comprise one or more tubules disposed in the central lumen and configured to deliver oxygen to ventilation ports in the second cuff, thereby injecting oxygen at high velocity into the patient's airway. In another embodiment, the means for advancing the airway tube into the patient's airway may comprise a pilot tube running the length of the exterior of the airway tube and an orogastric tube. The pilot tube may be configured to slide over and be guided by the orogastric tube after the orogastric tube has been positioned in the patient's airway.
a is cross-sectional view of a valve device in accordance with the invention showing the position of a rolling piston mechanism during positive pressure ventilation of a patient;
b is a cross-sectional view of the valve device of
a is a cross-sectional view of another valve device of the present invention showing the closed position of the valve mechanism;
b is a cross-sectional view of the valve device of
c is a cross-sectional view of a resuscitation system of the invention employing the valve device of
a illustrates one perspective view of a Locking Supraglottic Airway in accordance with the invention;
b illustrates another perspective view of the Locking Supraglottic Airway of
c is a sagittal view of patient's airway interfaced with the Locking Supraglottic Airway of
In one embodiment, the invention provides a method for performing cardiopulmonary resuscitation which comprises: 1) interfacing an airway system with a patient's airway, wherein the airway system includes at least a first lumen and a second lumen; 2) repeatedly performing CPR chest compressions on the patient; and simultaneously with the CPR chest compressions 3) applying a continuous vacuum to the first lumen for a period of time ranging from 10 seconds to the end of the CPR chest compressions; and 4) injecting an effective volume of oxygen gas into the person's lungs at high velocity through the second lumen.
As used herein, including the appended claims, the “patient” means any subject undergoing cardiopulmonary respiration (CPR), and may include both human and non-human animals.
As used herein including the appended claims, the phrase “airway system” is intended to include any system that is adapted to be interfaced with a patient's airway and has at least one lumen adapted to ventilate the patient's lungs during CPR; i.e. is adapted to move respiratory gases into and out of the patient's lungs. Such airway systems are sometimes referred to herein as “airway adjuncts” or “ventilation tubes”. Non-limiting examples of airway systems may include endotracheal tubes, supraglottic airway devices, Combitubes, obturator airways, laryngeal mask airways, and the like. Airway systems of the present invention also comprise at least a second lumen adapted to deliver oxygen gas into the patient's lungs.
As used herein including the appended claims, the phrase “CPR chest compressions” is intended to include any of the aforementioned CPR methods having a chest compression phase and a chest decompression (or recoil) phase. The chest compression phase serves to increase intrathoracic pressure and, thus, generate a pressure gradient between the thorax and the rest of the body, which in turn forces blood to the brain and other extra-thoracic organs. In addition, the chest compression phase causes the collapse of some of the bronchioles and, as a result, gas that is trapped in the distal portions of the airways is compressed. Thus, when there are respiratory gases in the lungs, the chest compression phase can help to open up the lungs and thus prevent atelectasis (collapse of the lungs). CPR chest compressions may also help to adequately exchange respiratory gases and help to maintain blood flow, as long as the lungs are partially inflated during the chest decompression phase. As a result, tissue oxygenation is maintained at a high level, CO2 can be removed, and blood can move from the right heart to the left heart with a better match between perfusion and ventilation. In the context of the present invention, CPR chest compressions may be viewed as providing a motor, and the combination of continuous high velocity O2-rich gas delivery and the application of a continuous vacuum to the patient's airway may be viewed as optimizing or improving the blood circulation to the heart and brain that is produced by that motor. In addition, the present invention may optimize the delivery of O2 to and CO2 removal from the patient's lungs.
The CPR chest compressions may also generate decompression phase negative intrathoracic pressure with each chest wall recoil. An ITD may be used to prevent respiratory gases from returning to the thorax during the chest wall recoil of the decompression phase of each CPR chest compression. By preventing respiratory gases from reentering the lungs during the decompression phase of CPR, the ITD helps maintain the decompression phase negative intrathoracic pressure. However, even when an ITD is used, the level of decompression phase negative intrathoracic pressure during standard CPR may oscillate with each compression and decompression cycle. This oscillation may result in a failure to maintain a continual negative intrathoracic pressure since at the peak of the oscillation, intrathoracic pressure may reach values that are at or above atmospheric pressure.
As used herein, the phrase “continuous vacuum” means that, when simultaneously combined with CPR chest compressions and the injection of high velocity O2 in accordance with the invention, the application of vacuum to the patient's airway is not interrupted for a period of time ranging from 10 seconds to the end of the CPR chest compressions. In some cases it could be for at least 15 seconds and in other cases at least 30 seconds to the end of performing CPR. In one embodiment of the invention, a continuous vacuum is applied to the patient's airway at a level sufficient to supplement the decompression phase negative intrathoracic pressure in the patient and remove respiratory gases from the patient's airway. In some embodiments, the continuous vacuum may be applied to the patient's airway by connecting a vacuum source to the lumen of an airway system such as an endotracheal tube. In other embodiments, the continuous vacuum may be applied to the patient's airway by other means; e.g. through a connector for the vacuum source at a remote location in a ventilation circuit or through a separate lumen, such as a nasal tube. As described above, the values of the intrathoracic pressure provided by the continuous vacuum may oscillate; e.g. with each CPR chest compression, and therefore the intrathoracic pressures values may not remain continuously negative relative to atmospheric pressure. However, it is understood that the negative pressure (vacuum) applied to the patient's airway will remain continuously negative for at least 10 seconds during the performance of CPR chest compressions and the injection of high velocity O2.
The oxygen gas injected into the patient's lungs in accordance with the invention is sometimes simply referred to herein, including the appended claims, as “O2”. It is understood that the term “O2” is intended to include mixtures of oxygen and other gases. In some embodiments, the second lumen through which O2 is delivered may be incorporated within the first lumen. For example, the first lumen may comprise the central lumen of a ventilation tube, e.g., an endotracheal tube, through which the second lumen may be disposed, and a continuous vacuum may be applied and maintained in the central lumen of the tube, e.g. through a valve mechanism or impedance threshold device.
In one embodiment of the invention, the volume of O2 delivered via the second lumen is sufficient to result in adequate oxygenation of the alveoli of the lungs (sometimes referred to herein, including the appended claims, as an “effective volume” or an “effective O2 volume”). In one embodiment, an effective O2 volume may be in the range of about 1 liter to about 20 liters delivered to the lungs during one minute of CPR chest compressions. Accordingly, these effective O2 volumes may be referred to herein in units of “liters per minute” or “L/min”. In some embodiments, an effective O2 volume of between about 3 L/min and 15 L/min may be preferred. In other embodiments, an effective volume may be about 12 L/min. In one embodiment, the second lumen is positioned within the patient's airway so as to deliver an effective O2 volume in close proximity to the patient's carina tracheae.
The velocity at which the effective O2 volume is injected into the lungs in accordance with the invention is largely dependent on the diameter of the delivery lumen. In one embodiment, an effective O2 volume may be delivered through one or more tubules having a lumen diameter small enough to generate what is sometimes referred to herein, including the appended claims, as a “high velocity” flow of O2 or “high velocity O2”. As used herein, including the appended claims, the term “high velocity” is intended to mean a velocity that is high enough to inject an effective O2 volume into the patient's lungs without interfering with the generation and maintenance of a continuous vacuum in the patient's airway. In one embodiment, high velocity O2 may have a velocity in the range of about 20 ft/sec to about 1100 ft/sec. In order to generate high velocity O2, the diameter of the lumen delivering the effective O2 volume may be in the range of about 0.1 cm to about 1.0 cm in some embodiment. In other embodiments, the lumen diameter may be about 0.25 cm to about 1.0 cm.
The injection of high velocity O2 into the patient's lungs through the trachea may produce a laminar or turbulent flow pattern. The flow pattern will depend upon a number of factors including the volumetric flow rate, O2 velocity, size of the one or more tubules used to inject the high velocity O2, and the size and architectural characteristics of the receiving airway system. Optimizing the degree of laminar and/or turbulent flow patterns may help to improve the overall efficiency of the invention. For example, in one embodiment O2 may be delivered as a high velocity O2 laminar flow in one direction primarily in the middle of the trachea, bronchi, and bronchioles. As a result, the flow of gases in the reverse direction resulting from the applied vacuum may move closer to the walls of these structures. Accordingly, a simultaneous bidirectional exchange of respiratory gases can occur in a relatively efficient manner. Physiological feedback sensors that measure flow and pressure, for example, may provide a means to further optimize the flow characteristics and, thus, the efficiency of the invention. Other physiological sensors may provide a similar kind of benefit.
Tracing panel A in
A device 20 suitable for the practice of one embodiment of the invention is shown in
A vacuum line 207 connected to a vacuum source 208 may be attached to device 20 at fitting 209, which communicates with central lumen 212 of device 20. When activated, vacuum source 208 generates a continuous vacuum in lumen 212 of device 20 and lumen 213 of ventilation tube 201, which results in a negative intrathoracic pressure in the patient's airway and lungs. This vacuum may generate a flow of respiratory gases R from the patient's respiratory system into lumen 213 of ventilation tube 201 and lumen 212 of device 20. An impedance threshold device (ITD) 210 may be attached to device 20 at fitting 215, which communicates with lumen 212. ITD 210 may be any of the known ITDs that prevent or impede respiratory gases R from flowing back into the patient's respiratory system thereby helping maintain negative intrathoracic pressure. Examples of ITDs may be found in the aforementioned U.S. patents previously incorporated herein by reference. ITD 210 may be set to maintain a negative intrathoracic pressure between about −2 mmHg and about −20 mmHg, and preferably between about −6 mmHg and about −12 mmHg. Optionally, one or more gauges to assess changes in pressure within device 20 could be attached, for example, via a Y-connector attached to fitting 209, 211, or another connection to device 20. Such gauge(s) may be used to provide the user with information regarding the pressure within device 20 at any point in time.
Device 20 may be activated by turning on O2 source 205 and vacuum source 208 as soon as ventilation tube 201 is inserted into the patient's airway. In some cases, O2 source 205 may be turned on before vacuum source 208. Simultaneously with the injection of O2 and the application of continuous vacuum, CPR chest compressions on the patient may be performed until there is a successful resuscitation, or other CPR procedures are performed. The continuous vacuum may be regulated by ITD 210, which opens at the preset cracking pressure, such that the intrathoracic pressure in the patient's respiratory system remains below atmospheric pressure, e.g. never exceeds a predetermined negative intrathoracic pressure value. Further, if the patient starts to breath during CPR or after a successful resuscitation the inspiratory resistance may never be greater that that to which ITD 210 is set. Thus, ITD 210 not only serves to regulate the applied vacuum but also provides a safety feature so that the patient can breathe, if spontaneous respiratory efforts are present during the CPR effort. Once the patient has been resuscitated and CPR is no longer performed, vacuum line 207 may be disconnected, or vacuum source 208 may be switched off if connected to a switch.
In another embodiment, the means for delivering high velocity O2 may be incorporated into the central lumen of a standard ventilator tube and may be separate from the means for applying the continuous vacuum. For example, in the embodiment illustrated in
In another embodiment, the present invention may be used in combination with traditional CPR methods that employ the periodic delivery of positive pressure ventilation to the patient's respiratory system; e.g. to expand the lungs fully. This additional step may in some cases add further benefit, particularly in a setting of prolonged resuscitations. Although such positive pressure ventilation is optional in the practice of the invention, it may serve a function which is the equivalent of a sigh during normal respiration in a healthy person. Both the sigh and intermittent positive pressure ventilation help to recruit more alveoli in the lungs, which may help prevent collapse and/or closure of the smaller airways and some alveoli.
Accordingly, in some embodiments of the invention, the patient may be ventilated actively during traditional CPR with either positive or negative pressure ventilation before or after the performance of CPR in accordance with the invention. For example, in one embodiment of the invention, a valve device may be attached to a source of positive pressure ventilation, such as a resuscitator bag, a mechanical ventilator or an anesthesia machine, so that ventilation may be applied immediately before or after CPR in accordance with the invention without having to change equipment. As one non-limiting example, device 40 shown in
Regulator valve 411 in
When clinically indicated, positive pressure ventilation may be periodically delivered to the patient through ventilator circuit 403 by opening and closing valve 411. The delivery of high velocity O2 to the patient may be provided through tubule 412 into lumen 414 and may be switched off and on using switch 409. A vacuum may be applied through vacuum line 408 to provide a continuous vacuum at a predetermined level in central lumen 413 of device 40 and ventilation tube lumen 414 by switching on switch 415 and closing valve 411. Alternatively, the supply of continuous vacuum may be switched off by switch 415 and valve 411 may be opened to provide for periodic positive pressure ventilation when necessary or desirable.
a and 5b illustrate a device 50 wherein positive pressure ventilation of the patient may be provided in one phase; e.g., when device 50 is being used in association with a CPAP system; and alternative continuous vacuum may be provided in a second phase in which the patient may be isolated from the CPAP system; e.g. when device 50 is being used to apply continuous vacuum to an airway system during CPR in accordance with the invention. Device 50 may comprise a housing 501 that defines a longitudinal lumen 502 and a branch lumen 503 in fluid communication with lumen 502. Piston 504 may be disposed within lumen 502, which may be sealed at the upper section of piston 504 by rolling diaphragm 505 and may be sealed at the lower section of piston 504 by rolling diaphragm 506. The lower section of piston 504 may comprise an internal chamber 507 having an entrance opening 508 at its lower end and an exit opening 509 in its side wall. Lumen 502 may communicate with a CPAP machine (not shown) through connection 510 and may communicate with a vacuum source (not shown) through vacuum connection 511. Oxygen catheter 512, disposed within branch lumen 503, may be connected at one end to an O2 source (not shown) through connector/valve 513 communicating with branch lumen 503. The opposite end of oxygen catheter 512 may extend the length of a patient's ventilation tube (not shown) so as to direct high velocity O2 to the patient's respiratory system. The ventilation tube may be connected to lumen 503 through patient connector 514.
Piston 504 and rolling diaphragms 505 and 506 may be moveable between the positions shown in
When positive pressure is not present in lumen 502, e.g., when the patient is undergoing CPR in accordance with the invention, piston 504 may be moved by the action of biasing spring 515 to the position shown in
Device 50 may be particularly useful when it is critical to prevent gas applied by the ventilator from reaching the patient during the administration of CPR, e.g., when anesthesia gas is applied to the patient by the ventilator. In addition, device 50 may provide a pressure-balanced system wherein the level of continuous vacuum being applied during CPR according to the invention does not affect the level of pressure required to activate the device when positive pressure ventilation is desired. During CPR in accordance with the invention, a continuous flow of high velocity O2 may be supplied to the patient's ventilation tube via oxygen catheter 512 and a continuous vacuum may be simultaneously applied as shown in
As previously described in connection with
c illustrates a resuscitation system 600 comprising a valve 60 coupled with a patient's endotracheal tube 608 through an adaptor 609. Adaptor 609 may comprise a body 610 configured to connect patient lumen 602 with central lumen 611 of endotracheal tube 608. O2 cannula 612 may enter body 610 through side port 613 and, when adaptor 609 is connected to endotracheal tube 608, may extend the length of central lumen 611. The proximal end 614 of O2 cannula 612 may be connected to a source of O2 and the distal end 615 of O2 cannula 612 may be disposed to inject high velocity O2 into the patient's lungs.
Valve 60 may comprise a housing 601 including a patient lumen 602 and a vacuum lumen 603 attached to a vacuum source (not shown). The vacuum source may be powered by a small Venturi attached to the O2 cannula 612 to produce a relatively low level vacuum, or may be an external vacuum source that produces a somewhat higher level of vacuum. Vacuum lumen 603 may be connected to patient lumen 602 through circumferential conduit 604. Biasing spring 605 may be disposed in housing 601 and may be adapted to exert downward force on circumferential sealing gasket 606 so as to keep sealing gasket 606 in the position shown in
During the compression phase of CPR chest compressions, the compression forces on the chest may generate a positive intrathoracic pressure which causes respiratory gases such as CO2 to flow from the patient's lungs and endotracheal tube 608 through patient lumen 602. The intrathoracic positive pressure in combination with the negative pressure generated by the low level vacuum applied through vacuum connection 603 acts to move sealing gasket 606 into the position shown in
In another embodiment, a continuous vacuum may be applied through vacuum connection 603 at a level sufficient to exert an upward force on sealing gasket 606 that is greater than the downward force provided by biasing spring 605. Accordingly, sealing gasket 606 may remain in the open position shown in
A variety of airway systems may be modified so as to be suitable for the practice of the invention. In one embodiment, one or more additional lumens may be added within an existing lumen of an airway adjunct specifically to carry O2 and direct it towards the patient's trachea. The additional lumen(s) may vary in size and design, but the diameter of the lumen(s) will be sufficient to deliver a high O2 velocity.
Airway adjuncts may be used to protect the lungs from aspiration as well as provide a means to ventilate patients who require assisted ventilation. A number of the previously mentioned airway adjuncts are available for this purpose, including without limitation endotracheal tubes, supraglottic airway devices, Combitubes, obturator airways, laryngeal mask airways, and the like. All of these airway adjuncts may be designed to maintain a seal when positive pressure ventilation is administered to the patient. Some of the airway adjuncts may be further designed to provide a means to prevent gastric contents from entering the lungs; e.g. the airway adjunct may comprise an additional tube portion that can be inserted into the esophagus or stomach. A number of variations are possible; e.g. to enable measuring pressures within the airway adjunct, delivering electrical therapy from the airway adjunct to the body, draining the stomach and gastric content, and the like. Some airway adjuncts are able to be placed in a blinded manner to facilitate ease of insertion. The latter are particularly helpful during the performance of CPR or in treating other life-threatening emergency where endotracheal intubation may be difficult. Most airway adjuncts have one or more cuffed balloons (“cuffs”) to seal off the trachea, the esophagus, the larynx, and other part of the airway tree such that when a positive pressure is delivered to the patient it is directed into the lungs. Dual lumen tubes have also been developed; e.g. to provide ‘jet ventilation’ to suction out mucous and deliver O2 within the lumen of an endotracheal tube.
Prior to the present invention there has not been a need to seal the patient's airway to allow for the application of a continuous vacuum, nor has there been airway systems adapted to accomplish this result. Standard cuffs are designed to prevent air leaks when positive pressure ventilation is delivered to the patient's airway. Pulling a continuous vacuum by an external means to create a negative intrathoracic pressure in accordance with the invention creates the opportunity for leaks to develop around such standard cuff because the forces on the tube generated by the vacuum may pull the tube inward and create gaps, especially in the nasopharyngeal region of the airway. In one embodiment, the present invention provides a means to easily and effectively generate and maintain a continuous vacuum without air leaks to the outside. The present invention is thereby useful for optimizing new therapies for the treatment of various conditions that take advantage of the beneficial effects of negative intrathoracic pressure. Such conditions include without limitation cardiac arrest, shock, stroke, brain injury and other states of low blood circulation.
The following description refers to
a shows a side view of a novel locking supraglottic airway (LSA) adjunct 70 that may be used in the practice of the present invention, and
Laryngeal cuff 709 may be positioned so as to surround airway tube 701 at the distal end of supraglottal section 703. Laryngeal cuff 709 may comprise cuff body 710 and nasopharyngeal extension 711, which may include a thickened wall portion 712 that serves as a stiffener. Laryngeal cuff 709 and esophageal cuff 706 may comprise balloons that could be inflated with a syringe. In one embodiment, both cuffs may be inflated with a single syringe, or a separate syringe may be used to inflate each balloon. O2 cannula 707 may extend the length of supraglottal section 703 from proximal end 706 to laryngeal cuff 709, where O2 cannula 707 may terminate as one or more ventilation ports 713 in laryngeal cuff 709. LSA 70 may also comprise pilot tube 714 attached to and extending the length of airway tube 701. Pilot tube 714 is adapted to receive orogastric tube 715.
LSA 70 may be interfaced with airway 716 of patient 717 as shown in
In one embodiment of the invention, high velocity O2 may be injected from O2 cannula 707 directly into the trachea of patient 717 through ventilation ports 713 by positioning laryngeal cuff 709 so that high velocity O2 exiting from ventilation ports 713 are physically directed toward the central lumen of the patient's trachea and main stem bronchi, as shown in
LSA 70 provides novel means for interfacing with the patient's airway in the practice of the invention. LSA 70 is designed with special nasopharyngeal appendage 711, which seals off the nasopharyngeal passageway 722 when inserted into the patient's airway 716. As shown in
As previously described, laryngeal cuff 709 may be a small balloon that has a unique feature, nasopharyngeal appendage 711, that serves to seal the nasopharyngeal region of the airway concurrently with the laryngeal-pharyngeal cavity. As a result, the patient's airway may be sealed and the airway tube may be stabilized so that it is more difficult for the airway tube to advance into the airway and leak when a continuous vacuum is drawn in the thorax relative to the atmosphere. In addition, LSA 70 may prevent gastric contents from being sucked into the patient's lungs. In contrast with prior art airway adjuncts that have inflatable cuffs to help seal off the airway and allow for the delivery of a positive pressure breath, LSA 70 is designed to assure the maintenance of continuous vacuum in the patient's airway and to continuously deliver high velocity O2 to the patient in accordance with the present invention. In addition, SLA 70 may provide a means for rapidly placing an airway adjunct blindly by the rescuer performing CPR, without stopping chest compressions, and may also protect against pulmonary aspiration. Laryngeal cuff 709 and nasopharyngeal extension 711, along with esophageal cuff 709, may assure a tight seal, even when a vacuum is generated below the position of SLA 70 in the patient's airway. SLA 70 also may provide an optional means to cannulate and/or suction the stomach through orogastric tube 715.
Referring to
The invention has now been described in detail for the purposes of clarity and understanding. However, it will be appreciated that certain changes and modifications may practiced within the scope of the appended claims.
