Webcast Central

The Strategic National Stockpile—The LTV-1200 Ventilator

Richard Branson, MSc RRT FAARC FCCM,
Angela King, RRT-NPS, RPFT
Eileen Malatino RN, MS

An expert faculty will review the Strategic National Stockpile focusing on the LTV 1200 ventilator. The setup up and operation of the ventilator will be detailed and clinical application of the ventilator to the patient will be discussed. The spectrum of disease associated with pandemic flu and the current findings (profound hypoxemia, failure of NIV, etc) will be presented and triage will also be discussed.

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Questions & Answers

Answers to the questions that were asked during the webcast.

  1. For the numerous questions and discussions about H1N1 influenza, treatments, and vaccine, please go to the following web site at CDC http://www.cdc.gov/h1n1flu/
  2. What is the process for requesting the vents from the SNS?
    Usually a need is determined by a locality; this could be a hospital or other treatment facility. A request for assets is usually sent according to local emergency protocols to the governor or their designee. A state of emergency may be declared by the governor before or during the particular event. The governor may then make a request to Health and Human Services for assets. Health and Human Services and other federal agencies and CDC discuss the situation, and then a decision is made to deploy assets. The SNS then coordinates with the state on the delivery strategy (that is: where, when, what, and how the delivery will take place). Once the supplies are delivered, the state disperses them to the needed sites. In certain cases medical supplies may be sent without a state requesting them. An example of this would be deployment of antivirals for a pandemic event. This automatic deployment could also include ventilators, but this maydepend on the size and scope of the event.
  3. Is the LP10 still around? For how long?
    The manufacturer ceased production of the LP10 in 2006. The LP10 is still maintained in SNS warehouses. The manufacturer is providing maintenance until 2011 for the SNS. After this time, the vents will be maintained by trained SNS warehouse technicians and phased out as needed.
  4. How many vents are there in the SNS?
    Currently there are approximately 4400 vents in the SNS. Approximately 4,400 are being added thru April 2010.
  5. How many Eagle vents are in the SNS?
    There are approximately 2400
  6. Where are the SNS warehouses? Also how are supplies distributed?
    The SNS does not divulge the location of warehouses for security reasons. How assets are distributed is a decision made by the state or local areas. The SNS generally delivers products to a warehouse(s) selected by the receiving state. It is usually the state/localities responsibility to disperse those assets where needed throughout the state.
  7. Do the SNS vents need to be purchased by the individual hospitals?
    There are no costs for SNS products. However, SNS ventilators are recovered by the SNS following an event or when no longer needed.
  8. We were told that for the non ventilator supplies, like masks and endotracheal tubes we would need to have cash to pay for these items. Is this true?
    As stated above in question 7, there is no cost (to states, territories or tribal nations) for the federal SNS assets
  9. Can these ventilators be purchased by hospitals?
    The SNS ventilators are not for sale and are recovered by the SNS following an event. However, the LTV 1200 and Impact 754 Eagle can be purchased from the manufacturer. The manufacturer of the LP10 discontinued production in 2006.
  10. Are the SNS vents only available in pandemic situations?
    The SNS vents can be used for many different scenarios, and are not limited to just pandemic influenza.
  11. Where would I get an Impact 754 Eagle ventilator manual?
    See the manufacturer contact info at http://www.impactinstrumentation.com/contacts.html
  12. Is there a way I can get a list of what the SNS has for respiratory supplies and equipment, and are there concentrators and nebulizer compressors?
    There are no O2 concentrators, O2 tanks, O2, or other compressors in the SNS. However, the respiratory supplies that the SNS has available include: hand held nebulizers (T-tube and aerosol masks), suction machines, O2 cannulas/masks, ET tubes & styletts, oropharyngeal airways, NG tubes, MPR bags and CO2 detectors, yankauer suction devices, suction catheters, laryngoscopes, N95 masks and other PPE, and albuterol nebulizer solution. Most of the supplies come in various sizes appropriate for adult, pediatric, and infant patients.
  13. Does the CDC plan on any web casts for medical providers.
    SNS usually works with organizations such as AARC or SCCM (Society for Critical Care Medicine) to provide training for end-users. At the AARC web site there is a ventilator hands-on workshop planned for December 4, 2009. http://www.aarc.org/education/meetings/congress_09/advance_program/workshops.cfm
  14. How much does the LTV vent cost?
    As a federal agency, the CDC may utilize contracts established by the Federal Government. Thus the cost may be different than for other entities. Commercial pricing may be obtained from the manufacturer.
  15. Is there an oxygen connecting hose?
    Yes, a green high pressure O2 supply hose
  16. How will SNS recover equipment post use?
    Vents distributed by the SNS will be tracked and recovered post event. Only the durable medical equipment is recovered. Any disposable supplies that remain will probably not be recovered.
  17. How long are the vents stored and how often are they tested to make sure they work?
    All SNS vents are stored in SNS temperature controlled warehouses and have scheduled charging done per manufacturer’s guidance by SNS warehouse technicians. All vents are sent to the manufacturer annually on a rotation schedule for preventive maintenance.
  18. Are there endotracheal tubes included, and who supplies the full face mask?
    Endotracheal tubes are not included with the kitted vents but are included in the SNS 12-Hour Push Package and Managed Inventory. These items can be requested from the SNS if needed. The SNS does not provide the face mask for use with the vent. This item is available from the manufacturer.
  19. Will the LTV laminated Setup Cards and/or the CDs be made available from the AARC and/or the company for viewing?
    Providing these items on-line via AARC web site and manufacturer’s web site is being developed.
  20. Are the SNS LTV circuits disposable?
    Yes
  21. Will the Eagle 754 circuits work for this ventilator?
    No, all SNS ventilators have proprietary circuits and thus are not interchangeable
  22. What is the availability of the proprietary circuit in the event of a national event?
    For all of the SNS vents, additional circuits will be available from the SNS in the resupply kits or SNS Managed Inventory. The SNS will also work with manufacturers to acquire additional circuits if needed.
  23. Is there a DC adaptor in the LTV 1200 kit?
    Yes, 12 ft auto power cable
  24. Are orders first come first serve or based on need? What is the expected average time of receipt once requested?
    For a pandemic influenza event, SNS ventilator distribution is set to go out pro rata – meaning each state and territory will receive SNS vents based on population. However, the trigger for release for the pro rata vent shipment will depend more on clinical need, as defined at the time of the event by CDC Subject Matter Experts. For pandemic flu, the vents are currently not an automatic line item that would be released. They are considered a scarce resource with VERY limited manufacturing capacity, thus the release may need to be more controlled. Arrival time for vents may be between 24-36 hrs from the time the SNS has received federal approval to deploy the items. This time may vary depending on the size and scope of the event.
  25. Can you set up vents in an ambulance?
    SNS vents have battery back-up and can be used to transport patients.
  26. Is humidification provided?
    Heat Moisture Exchangers (HMEFs) are provided,
  27. Is a 50 psi gas source required? O2 or Air?
    A 50 psi gas source is not required to power the ventilators, but oxygen will almost certainly be required for treating pandemic patients. Oxygen can be delivered via a 50 psi gas source or via a low flow into the inlet of the ventilator.
  28. Does the LTV 1200 still have external peep and is there still a moisture issue with the peep device?
    No, the PEEP on the LTV 1200 is internal. There is no moisture problem.
  29. What weight is considered “infant" for the LTV 1200?
    5kg to 10 kg
  30. Can the LTV 1200 be used on patients smaller than 5 kg.
    The use of the LTV 1200 on patients < 5 kg is not FDA approved. That being said, speaker Angela King, RRT has seen many patients < 5 kg successfully ventilated with the LTV 1200. To Angela's knowledge, all of the small infants were ventilated using pressure ventilation. If you are considering this application, it is paramount that you make sure the referring physician is aware that the application is not FDA approved, and of course closely monitor the patient on the device. It would also be a good idea to discuss with a CareFusion clinical specialist to get tips on setting the Extended Menu settings for a small infant.
  31. When used with a mask, does the LTV 1200 compensate for a leak around the mask?
    The LTV 1200 has leak compensation, up to 6 LPM. With a reasonably good fitting, non-vented mask, the LTV can be used successfully non-invasively. It does not leak compensate for large leaks. (Note: A "non-vented" mask does not include passive exhalation ports).
  32. Does altitude affect operation?
    The LTV-1200 does not compensate for altitude. At normal cabin pressures in commercial aircraft (8,000 feet) the LTV will deliver a tidal volume approximately 7-10% greater than set. The stiffer the lung and greater the compressible volume of the circuit, the smaller the increase in tidal volume associated with altitude. This is within the +/- 10% specified by ASTM for tidal volume accuracy.
  33. Is there an inlet dust filter feature for use in the field?
    There are 2 filters on the left side of the LTV. The small black sponge filter at the top is the fan filter. It filters the air that enters the LTV interior. The large white sponge filter at the bottom of the LTV filters the air that is sent to the patient. Both of these filters can be cleaned with a mild detergent and warm water, then rinse. Allow the filters to air dry before reinstallation.
  34. 2 batteries equal how much battery time?
    LTV manufacturer states 60 min for internal battery and 5 hours for external battery. Keep in mind that battery run times vary depending on the vent settings, the patient’s lung compliance, and the battery age and condition.
  35. For the HMEF how often should it be changed and are additional HME available?
    Research demonstrates that the same HME can be used on the patient for 3-5 days without being changed. Of course you should assess the patency of the device routinely and if it is occluded by blood or secretions it should be changed as needed. Additional HMEF will be available from the SNS in the Re-Supply kits.
  36. Has the LTV 1200 been used on H1N1 flu pts in severe ARDS? How successful was it?
    Is there evidence that documents that the LTV 1200, LP10, or Impact 754 Eagle is capable of ventilating severe ARDS patients with very low compliance and high airway resistance?
  37. To date there has not been such a great number of H1N1 patients that these ventilators have needed to be used in these patients. However, both ventilators are used by the USAF for CCATT transports of critically ill patients with ARDS following trauma. The University of Cincinnati has used both devices for prolonged periods of time in patients with severe ARDS without difficulty. The one limitation is the peak flow of the 754 is 60 L/min – which, in awake patients with a high demand can result in an increased work of breathing.
  38. Is there any special decontamination process after using the LTV on an H1N1 patient?
    Any durable medical equipment should be decontaminated according to local hospital/medical treatment facility infection control guidelines and manufacturer recommendations.
  39. Can Heliox be used with the LTV 1200 regardless of FDA approval?
    Given that the use of Heliox with the LTV is not FDA approved, and given there are a number of technical issues to be mindful of, it is strongly recommended that the therapist consult with the referring physician and with a CareFusion clinical specialist, prior to initiating the therapy. Speaker, Angela King, RRT, has seen Heliox used with the LTV, under close supervision by the physician and respiratory therapist. In addition, some therapists have done bench testing on the use of Heliox with the LTV. The clinician must be aware that the delivered tidal volume is increased as compared to the set tidal volume when using Heliox. The volume measurement of the LTV is also inaccurate in the presence of Heliox. Other considerations include making a label or sign on the LTV to indicate that Heliox is in use, and making sure you understand that the FIO2 display on the front panel is not accurate when you are using Heliox. Again, it is strongly recommended that you speak with one of CareFusion’s clinical specialists prior to attempting the use of Heliox with the LTV.
  40. Statistics were shown about a 90% successful set up of the LTV 1200 by adult lay people. Was this achieved during a simulated emergency situation? Was this tested on adult, pediatric or infant patients, or any combination of set-ups?
    The testing was done in a non-emergency simulation. Participants were timed and were not allowed to observe one another. The participants were given both pediatric and adult circuits and masks—but the mannequin was an adult. Participants were asked to set up the vent properly using only the Emergency Set Up card (including choosing the correct circuit for the patient and setting for the correct patient type). After the first testing session, the card was revised to address some of the issues noted during the first testing session. For the second testing session, participants used the enhanced Set Up card; the average score was over 90%. The purpose of the testing was to help design an Emergency Set Up card that was easy to understand.
  41. Does the LTV 1200 come with the graphics monitor?
    No, only the vent itself is supplied from the SNS.
  42. Does the circuit include an MDI delivery device? MDI insert or actual MDI?
    The Go Pack includes 1 adult MDI adapter and 1 pediatric MDI adapter. The adapter can be placed in-line on the circuit.
  43. I heard that the SNS has 2 other vent models and don’t recall which ones. Is training available about these vents as well?
    The AARC did a web cast about two years ago on the Impact 754 Eagle and the Puritan Bennett LP10. This web cast is archived on the AARC web site and may be viewed at any time.
  44. Is there evidence that documents that the LTV 1200, LP10, or Impact 754 Eagle is capable of ventilating severe ARDS patients with very low compliance and high airway resistance?
    At present there are no reports of using the SNS vents for treating H1N1. However, the 754 and LTV-1200 have been tested in models of very low lung compliance and found both ventilators capable of delivering the set rates and tidal volumes required. The lung compliance settings were based on reports from hospitals with large clusters of flu patients. Additionally, both devices have been used to transport military casualties with ARDS on PEEP as high as 20 cm H2O without difficulty.
  45. What were the articles Rich Branson referred to about use of ventilation in patients with ARDS as a result of complications of H1N1 flu?
    The two publications mentioned are:
    1. Intensive care adult patients with severe respiratory failure caused by Influenza A (H1N1) virus in Spain. http://www.ncbi.nlm.nih.gov/pubmed/19747383?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel. Pubmed_DefaultReportPanel.Pubmed_RVDocSum
      Rello J, Rodriguez A, Ibanez P, Socias L, Cebrian J, Marques A, Guerrero J, Ruiz-Santana S, Marquez E, Del Nogal-Saez F, Alvarez-Lerma F, Martinez S, Ferrer M, Avellanas M, Granada R, Maravi-Poma E, Albert P, Sierra R, Vidaur L, Ortiz P, Prieto Del Portillo I, Galvan B, Leon-Gil C, H1n1 Semicyuc Working Group T.Crit Care. 2009 Sep 11;13(5):R148. [Epub ahead of print]
    2. MMWR July 17, 2009 / 58(27);749-752 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5827a4.htm Intensive-Care Patients With Severe Novel Influenza A (H1N1) Virus Infection-Michigan, June 2009

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