FPH US and Mexico Investor Day 2018

1

2

3

•
−
−
•
•
−
−
4

•
−
−
−
•
−
−
−
−
−
5

•
•
•
−
−
−
•
•
6

7

8

•
•
•
•
•
Source: Tijuana Medical Cluster/Instituto Nacional de Estadística y Geografía (INEGI)
9

3
10

11

5
12

13

14

*Source: Ruiz-Morales y Asociados Firm
15

16

17

18

19

to
20

21

22

23

17
24

25

26

27

28

29

30

•
•
−
−
−
−
•
•
−
−
−
•
−
31

32

•
−
−
•
•
−
−
−
−
33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

•
−
−
−
•
•
•
49

•
•
•
•
•
•
50

•
•
•
•
•
51

52

53

Nasal High Flow Therapy:
UCSD Perspective
Timothy A. Morris, M.D.
Professor of Medicine
Division of Pulmonary and Critical Care Medicine
Medical Director, Respiratory Care
University of California, San Diego
Disclosure: Timothy Morris, M.D. will be reimbursed by Fisher & Paykel Healthcare
for any expenses incurred in connection with his participation in today’s event.
54

UC San Diego Healthcare
•UCSD Hillcrest Medical Center (390 beds)
•Jacobs Medical Center (364 beds)
•Sulpizio Cardiovascular Center (54 beds)
•Average Daily Census: 504
•Annual Discharges: 29,200
•Average Length of Stay: 6.13
•Emergency Visits: 77,603
55

My roles
•Medical Director, Respiratory Care Department
•Medical Director, Pulmonary Physiology Lab
•Clinical Service Chief, Pulmonary and Critical Care
•Critical care physician
•Past-president, National Association for Medical
Direction of Respiratory Care
•President, Respiratory Compromise Institute
56

Clinical niches at UCSD
•Provide oxygen to alveoli
57

Provision of oxygen
•FO
2
of
–2 LPM NC
–6 LPM NC
–10 LPM face mask
–100% non-rebreather mask
58

Inspiratory flow rates
350 L/min
30 L/min
59

Supplied vs entrained air
Inspiratory flow
2 LPM 100% O
2
21% O
2
??% O
2
60

Supplied vs entrained air
Inspiratory flow
6 LPM 100% O2
21% O2
??% O
2
61

Supplied vs entrained air
Inspiratory flow
60 LPM 100% O2
21% O2
??% O
2
62

Clinical niches at UCSD
•Provide oxygen to alveoli
–Pneumonia
–Lung inflammation
–Pneumothroax
63

64

65

66

67

Clinical niches at UCSD
•Provide oxygen to alveoli
•Provide water to airways
68

Humidity
69

Jungle humidity
70

Alveoli are 100% humid at 37 C
71

Where does the water come from?
Ambient air this week
Alveolar air
72

Evaporation from airways
73

Mucociliary clearance
74

Clinical niches at UCSD
•Provide oxygen to alveoli
•Provide water to airways
–bronchiectasis
–cystic fibrosis
–chronic bronchitis
–asthma
–diffuse panbronchiolitis
–plastic bronchitis
–primary ciliary dyskinesia
75

Clinical niches at UCSD
•Provide oxygen to alveoli
•Provide water to airways
•Mechanical support to ventilation
76

Increase the inspiratory support
PEEP
Paw
77

Clinical niches at UCSD
•Provide oxygen to alveoli
•Provide water to airways
•Mechanical support to ventilation
–Neuromuscular weakness
–Rib fractures etc.
78

Increase the PEEP
PEEP
Paw
79

Normal Alveoli
80

Emphysema
81

Beginning of Exhalation
Normal
Airway Obstruction
82

End of Exhalation
Normal
Airway Obstruction
83

Applied Pressure to Counter PEEP
i
Applied Pressure
Airway Obstruction
84

Clinical niches at UCSD
•Provide oxygen to alveoli
•Provide water to airways
•Mechanical support to ventilation
–Neuromuscular weakness
–Rib fractures etc.
–COPD
85

Clinical niches at UCSD
•Provide oxygen to alveoli
•Provide water to airways
•Mechanical support to ventilation
•Increase intrathoracic pressure
86

CHF
87

CHF and positive intra-thoracic pressure
88

Positive intra-thoracic pressure during CHF...
•decreases venous
return
•reduces right ventricle
bulging into left
ventricle
•decreases left
ventricle work
89

Clinical niches at UCSD
•Provide oxygen to alveoli
•Provide water to airways
•Mechanical support to ventilation
•Increase intrathoracic pressure
–Cardiomyopathy
–Congestive heart failure
90

Clinical niches at UCSD
•Provide oxygen to alveoli
•Provide water to airways
•Mechanical support to ventilation
•Increase intrathoracic pressure
Routine use
Growing use
Beginning use
Beginning use
91

Thank you
92

93

•
•
•
•
•
94

•
95

96

97

•
−
−
−
−
98

•
•
•
•
−
99

•
•
−
•
•
−
−
100

•
•
•
−
−
−
101

102

HCD COPD Program
The COPD Program offers comprehensive,
personalized care for people with Chronic
Obstructive Pulmonary Disease (COPD)
John Olivas, President
Rodolfo Blain, VP HME
103

John Olivas and Rodolfo Blain will be reimbursed by Fisher & Paykel Healthcare for any expenses incurred in
connection with their participation in today’s event.
Disclosure
104

Negative Pressure Wound Therapy
Hospital Beds
Gel Mattresses
Low Air Loss Mattresses
Trapeze Bars
Wheelchairs
Bariatric Equipment
Walker With Wheels
Rollators
Enteral Nutrition
Feeding Pumps
Tens Units
Incontinence Supplies
Ventilators
Oxygen Concentrators
O2 Conserving Devices
Nebulizers
CPAP/BiPAP/BIPAPST
Suction Machines
Pulse Oximetry
Equipment for Improved Living
Durable Medical Equipment
Asthma Education
Clinical Assessment –Hospital (pre-discharge)
Clinical Assessment –Home/Family Evaluation and
Education
Clinical Assessment—Respiratory Evaluation and
Consultation
Home Safety Assessment
OSA 90-day Follow Up and Mask/HG/Tubing
Replacement Service
Overnight Oximetry
CPAP/BiPAPCompliance Reporting
Portable Home/Sleep Study (Non-Medicare)
Clinical Staff Training/DME Education
DME Client Services
105

COPD Program Goals
Prevent disease progression
Relieve symptoms
Improve exercise tolerance
Improve health status
Prevent and treat complications
Prevent and treat exacerbations, reducing hospital admissions
Improve overall quality of life
People who learn about their COPD and treatment plan are better able to
recognize symptoms and take appropriate action.
106

COPD Education
What is COPD
Respiratory System
What Happens to Your lungs with COPD
Medication Delivery Devices
Metered Dose Inhaler and Proper Use
Nebulizer and Proper Use
Albuterol
Home Oxygen
When to call your Primary Care Physician
107

Standard COPD Program Length
The standard COPD program stay will last 5 weeks with an extra 1 week to be reserved for as
needed (PRN). The first week will run Monday through Friday with scheduled 1 hour daily sessions
as follows:
Week 1, Monday through Friday with scheduled 1 hour daily sessions to accommodate a Q4 hour
frequency
Week 2, Monday, Wednesday and Friday with scheduled 1hour sessions to accommodate a Q6 hour
frequency
Week 3, Tuesday and Thursday with scheduled 1 hour sessions to accommodate a QID frequency
Week 4, Tuesday and Thursday with scheduled 1hour sessions to accommodate a TID and PRN
frequency
Week 5, Wednesday with scheduled 1 hour sessions to accommodate and re-enforce a bid and PRN
frequency
Week 6, to be used as needed to evaluate and titrate or reevaluate the patient's response and/or lack of
response to therapy.
108

COPD Program and Airvo
INDICATION FOR AIRVO 2 HIGH FLOW HUMIDIFICATION
Reoccurring Hospitalizations due to COPD exacerbation(Yellow Zone)
Potential for/or Presence of Atelectasis
Bronchospasm
Bronchiectasis
Need for Hydration and of Retained Secretions
Need for Heated Humidification
–Impaired MucociliaryClearance of Secretions from Lung
–Retained Bronco Pulmonary Secretions
–Tracheal bronchial Mucosal Congestion and Laryngeal Stridor
109

AirvoCase 1
70 y/o Hispanic female presented with diagnosis of COPD
3 prior hospitalizations last one 04/03/18
Admitted into COPD program on 05/16/18 w/Airvo
Followed for the initial four week COPD program visits in which her vital signs
remained within normal limits, but with a noted improvement of her bilateral
breath sounds to clear throughout
No Further Hospitalizations since
110

AirvoCase 2
83 y/o Hispanic male presented with diagnosis of COPD
Multiple hospitalizations for exacerbation of his COPD
Most resent hospitalization was in 06/17/18 for 10 days
Admitted post hospitalization 06/28/18
His bilateral breath sounds were with rhonchi to upper lobes and diminished
to the lower bases with a nonproductive dry cough. It must be noted, that the
patient has a long history of exposure to asbestos since he worked with that
material in his youth.
On 07/18/18 there was a marked improvement to his bilateral breath sounds
with scattered rhonchi throughout and expiratory wheezing to upper lobes
with a productive cough on demand with small amount of thin clear
secretions.
No Further Hospitalizations since
111

AirvoCase 3
66 y/o Hispanic male presented with diagnosis of COPD
Two prior hospitalizations for COPD exacerbation
admitted into COPD program on 07/18/18
patient completed the COPD program with unremarkable results and no visits
to the ER and no hospitalizations.
112

113