Providing a Patient Care Continuum for “At-Risk ...

2/18/2021

Confidential ‐ For Internal Use Only 1

Confidential - For Internal Use Only

Caring For Your Existing Patients’ Airway Clearance Therapy Needs

Providing a Patient Care Continuum for “At-Risk” Respiratory Patients


Our Presenter

Matt Stamm, RRT• Registered Respiratory Therapist (RRT) since 1997

• 20 + years of experience working with patients, clinicians and physicians in the field of Respiratory Care, Patient assessment, Education, Treatment of Respiratory disease processes

• Licensed Respiratory Care Practitioner in the State of Florida


Learning Objectives

• Discuss the symptoms that would indicate the need for advanced airway clearance therapy

• Understand airway clearance device options and how they benefit patients

• Recommend treatment options that may decrease lung infections and improve quality of life

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Airway Clearance Therapy

Review of Common Airway Clearance Techniques and Advanced Airway Clearance Therapy - HFCWO


What is Airway Clearance Therapy

• Airway clearance is the non-pharmacological intervention that helps to remove secretions from the lungs, resulting in fewer exacerbations and increased breathing.¹

• Airway clearance therapy utilizes physical or mechanical means of percussion and vibration to mobilize mucus and phlegm to facilitate airway clearing by coughing.

• Available studies suggest that airway clearance techniques are beneficial, with improved Quality of Life (QoL) scores, mobility/exercise capacity, reduced cough and sputum volumes.²

• The appropriate airway clearance must be prescribed by a physician.

• Airway clearance techniques are standard treatment for patients with bronchiectasis, disorders of the diaphragm, cystic fibrosis and neuromuscular diseases.¹

1. http://bronchiectasis.com.au/physiotherapy/principles‐of‐airway‐clearance/choosing‐a‐technique.2. Lee 2013, Lee 2008.


Common Airway Clearance Therapy Techniques

Chest Physiotherapy (CPT)Involves a therapist or caregiver gently but firmly patting the chest and back to loosen thick mucus in the lungs.

Huff CoughingInvolves taking a breath in, holding it briefly, and actively exhaling as if trying to “fog up” a mirror. Coughing is one of the easiest airway clearance techniques and helps to release mucus from the lungs and passed into airways for clearing.

Hypertonic Saline SolutionSterile sodium chloride (salt) solution inhaled through a nebulizer to thin the mucus. Available in different concentrations, most commonly 3% and 7%.

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Manual Hand Chest PT

• Chest percussion therapy or Chest physiotherapy (CPT) – a broad term for treatments using clapping or percussion techniques over all segments of the lungs to help move mucus from breathing passages.

• CPT has been the gold standard for years

• Patients may have difficulty receiving effective treatment at home away from a clinical setting


Huff Coughing

• Huffing, also known as huff coughing, is a technique that helps move mucus from the lungs. It should be done in combination with another ACT.

• Huffing is not as forceful as a cough, but it can work better and be less tiring. Huffing is like exhaling onto a mirror or window to steam it up.

The Huff Coughing Technique

• Sit up straight with chin tilted slightly up and mouth open.

• Take a slow deep breath to fill lungs about three quarters full.

• Hold breath for two or three seconds.

• Exhale forcefully, but slowly, in a continuous exhalation to move mucus from the smaller to the larger airways.

• Repeat this maneuver two more times and then follow with one strong cough to clear mucus from the larger airways.

• Do a cycle of four to five huff coughs as part of your airway clearance.


Common Airway Clearance Techniques

PEP Devices – Positive Expiratory Pressure

Hand‐held device that creates vibration and resistance when exhaling into the device. The vibration and resistance aid in moving mucus up and out of the airways.

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PEP Device Example – How an Acapella Works

• Inside the valve is a small steel ball in a cone shaped valve. Exhaling into the device moves the ball up and down, doing two things—vibrating the airways and exhaling against resistance.

• The vibration opens up the airways, facilitating the movement of mucus. Exhaling against resistance creates back pressure or positive pressure which allows mucus to move from peripheral airways to the larger central airways so it can be coughed out


High Frequency Chest Wall Oscillation Therapy

Origins of HFCWO

• Originally invented in the late 80’s to treat cystic fibrosis.

• The aim of the therapy was clearing mucosal secretions from the respiratory tract to improve lung function.

Advanced Airway Clearance Therapy - HFCWO

• Two Technologies – Evolving towards mobility, adherence and quality of life

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HFCWO – Traditional Compression-Style Vests

• The vest if filled with compressed air causing the vest to inflate and squeeze the patient’s chest.

• Air pulses inflate the vest at a rate of 6-20 times per second.

• The sensation is similar to that of a blood pressure cuff.

• Traditional Compression style vests have two ways to adjust the therapy – how tight it squeezes the torso and how fast it pulses.

Vest device that plugs into an electric outlet and uses an air compressor to inflate and deflate a vest through tubes to oscillate the torso.

Hillrom – The Vest® Electromed – Smart Vest® Respirtech - inCourage®

HFCWO - Mobile Therapy

• Portable vest device that oscillates against the chest wall to loosen mucus so it can be coughed up more easily. Allows for free movement during treatment


AARC Considerations

All HFCWO devices have AARC Considerations. In addition, the Monarch® has Contraindications per the FDA, as clearly indicated on the product website.

• https://www.hillrom.com/en/products/the-vest-system-105/

• www.smartvest.com

• www.vest.respirtech.com

• www.afflovest.com

• https://mymonarch.com/monarch-system/

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Technology – Moving Toward Mobility

MOBILITY

• Battery powered and fully mobile during use so patients can stay active even during treatment

PORTABILITY

• Travel friendly designs

• Travel cases included

PATIENT ADHERENCE

• The freedom of untethered treatment option results in enhanced patient adherence


Technology – Moving to Lightweight Systems

Mobile Systems

• AffloVest: ~5 lbs. to 8.5 lbs. ( 7 sizes ranging from XXS to XXL)

• Monarch: 13 lbs. (1 size)

Stationary Systems

• 17 lbs. average weight (including generator)

Age and size of patient can influence weight tolerance


Benefits of Mobile HFCWO

Can be used in conjunction with other treatments

• Use with postural drainage

•Use while exercising or other daily activities

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Patient Benefits - Airway Clearance Therapy

Early diagnosis and implementation of airway clearance can reduce morbidity and mortality¹

• Airway clearance aims to reduce airway damage by halting the vicious cycle of bacteria and subsequent inflammation, reduce the number of pulmonary exacerbations and hospitalizations and improve health related quality of life²

• Pneumonia has a high mortality rate – 6.5% of pneumonia patients die during hospitalizations; 13% die within 30 days of discharge³

• The American Thoracic Society (ATS) states that about 1 million adults in the US seek care in a hospital due to pneumonia every year, and 50,000 die from this disease⁴

1. Volsko, T. Airway Clearance Therapy: Finding the Evidence. Respiratory Care. October 2013.2. O’Neill, K. et al. Airway Clearance . Mucoactive Therapies and Pulmonary Rehabilitation in Bronchiectasis. Respirology 2019.3. Ramirez, J. et al . Adults Hospitalized With Pneumonia in the United States. Incidence. Epidemiology, and Mortality. Clinical Infection Diseases. December 2017. 4. https://www.thoracic.org/patients/patient-resources/resources/top-pneumonia-facts.pdf


Patient Benefits - Airway Clearance Therapy

• HFCWO is a valued therapy for better pulmonary health due to the large prevalence of respiratory related health problems • Studies indicate 42% of COPD patients may have bronchiectasis¹

• Clinical overlap between COPD, asthma and bronchiectasis can easily contribute to diagnostic errors²

• Majority of people with COPD have hyperinflation of the lungs³

• 52 Medicare approved ICD-10 codes for HFCWO therapy to clear excessive mucus from the lungs

• HFCWO provides appropriate bronchial hygiene which reduces mucus and mucus plugging and improves O₂/CO₂ gas exchange⁴

1. Kosmos E, et al., Bronchiectasis in Patients with COPD: An Irrelevant Imaging Finding or a Clinically Important Phenotype? CHEST 2016.2. Aksamit, T. et al. Bronchiectasis and Chronic Airway Disease: It is not just about Asthma and COPD. CHEST Journal. October 2018.3. Gagnon, P. et al. Pathogenesis of Hyperinflation in Chronic Obstructive Pulmonary Disease. International Journal of COPD. 2014.4. Perez, C. Airway Clearance and Bronchiectasis. RT Magazine. 2016.


The Vicious Cycle of Lung Infections

Chest Infections, often recurring

Antibiotic treatments

Daily productive cough

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The Vicious Cycle starts with a respiratory illness

• The “At-Risk” person has respiratory illness symptoms like a chronic cough or shortness of breath

• The “At-Risk” person is diagnosed with COPD, asthma, chronic bronchitis

• The respiratory illness becomes a chest infection



Now the chest infection needs to be treated

• A common treatment plan is antibiotics to break up the infection



The result of the symptoms has been treated, but not the symptoms themselves

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Chest Infections, often recurring




Breaking the Vicious Cycle of Bronchiectasis

Chest Infections, often reoccurring



Other treatments tried and failed

Airway Clearance

Airway Clearance


Airway Clearance Therapy = Preventative Healthcare

Preventative healthcare has been around for a long time – for preventing Type II Diabetes or Heart Failure – but now it’s time to promote good, bronchial hygiene for your at-risk pulmonary patients to be in the best health possible for normal, everyday living now and in the future for when the next virus comes.

Advanced Airway Clearance Therapy is the best solution for at-risk pulmonary patients because it provides a preventative treatment option

that results in reduced, recurring hospitalizations and better overall health.

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The Airway Clearance Therapy Patient

Symptoms that Indicate the Need for Airway Clearance


Who is the “At-Risk” Respiratory Patient?

• Pulmonary Compromised

• History of Pneumonia

• Underlying Chronic Respiratory Conditions

• COPD

• Bronchitis, Emphysema (under COPD umbrellas)

• Chronic Asthma

• Bronchiectasis

• Disorders of The Diaphragm (Relaxation and Flattening of the Diaphragm)


Who is the “At-Risk” Respiratory Patient?

• Chronic Cough

• Productive Cough

• Ineffective Cough

• Frequent lung infections – pneumonia

• Mucus hypersecretion

• Mucus retention

• Mucus plugging

• Shortness of breath (dyspnea)

• O₂/CO₂ gas exchange resulting in CO₂ retention (hypercapnic)

• Pulmonary exacerbations

• Hyperinflation of the lungs

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Bronchiectasis

• Bronchiectasis is a chronic condition that occurs when the walls of the airways (bronchi) thicken as a result of chronic inflammation and/or chest infections. This condition results in mucus accumulation.

• Symptoms include a persistent cough over months or years which produces mucus daily. Patient often experience breathlessness.


Bronchiectasis Pathology

This computed tomographic (CT) image of the lungs shows dilation of the bronchi characteristic of bronchiectasis (arrows). The large white structure in the center is the aorta and the darker areas are normal lung.


Bronchiectasis is Underdiagnosed

• Out of a total U.S. COPD population of 12 million people, 42% may have bronchiectasis.¹

• 5 million people may be misdiagnosed and receiving inadequate treatment

• 70,000 new patients in the U.S. diagnosed with bronchiectasis yearly.²

1. Kosmas, E. et al. Bronchiectasis in Patients with COPD: An Irrelevant Imaging Finding or a Clinically Important Phenotype? CHEST. 2016; 150(4):894A..2. Weycker D. et al., Prevalence and Economic Burden of Bronchiectasis. Clin Pulm Med 12:205, 2005

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Bronchiectasis is Underdiagnosed

• Out of a total COPD population of 12 million, 5 million patients (42%) may have bronchiectasis. 70,000 new patients in the U.S. diagnosed yearly.¹

• According to a recent study, the under-diagnosis of bronchiectasis may be due largely to its grouping under chronic obstructive pulmonary disease (COPD). “The clinical features of the COPDs frequently overlap,” wrote Jane M. Braverman, PhD, in the article “Airway Clearance Indications in Bronchiectasis: An Overview.”

• Contributing further to underdiagnosis is the fact that bronchiectasis is a manifestation of other airway diseases such as COPD, cystic fibrosis, and Nontuberculous mycobacteria (NTM), meaning that bronchiectasis may simply be overlooked by a diagnosis of severe symptoms of these other disease states.

• Other triggers of bronchiectasis include exposures to caustic fumes in the environment, lung infections, or blocked airways.²1. Weycker D. et al., Prevalence and Economic Burden of Bronchiectasis. Clin Pulm Med 12:205, 2005.2. Bronchiectasis is increasingly recognized as being underdiagnosed. Lung Disease news, February 9,2015, Maureen Newman.


What’s the Clinical Issue?


Hyperinflation of the Lungs

• Hyperinflated lungs occur when air gets trapped in the lungs and causes them to overinflate. It is often seen in people with COPD.

• Hyperinflation occurs when the lung tissue has been damaged and loses its elasticity

• The diaphragm will appear flattened due to the structural changes in the lungs and surrounding tissue. This is a result of hyperinflation, as the large lungs push against the diaphragm forcing it downward.

• This “relaxation or flattening of the diaphragm” can be seen on a chest X-ray.

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Symptoms Explained

• COPD and other diseases that cause lung hyperinflation may cause diaphragmatic paralysis.¹

• Respiratory patients with diaphragm abnormalities may have compromised ability to take deep inhalation breath or produce effective coughs.

• Due to the loss of diaphragmatic tension, patients are unable to produce an effective cough to mobilize secretions.

• This may lead to mucus plugging, further compromising the function of proper O₂/CO₂ gas exchange.

• This may leave the patient hypercapnic (CO₂ retentive) and at high risk for exacerbations.

• Frequent pulmonary exacerbations may lead to an increased diaphragmatic load and further injure the diaphragm.

1https://pulmccm.org/review-articles/diaphragmatic-dysfunction-and-respiratory-illness-review-nejm/


Dysfunction of the Diaphragm

• Hyperinflation is one cause of diaphragmatic dysfunction

• Dysfunction of the diaphragm ranges from a partial loss of the ability to generate pressure (weakness) to a complete loss of diaphragmatic function (paralysis)

McCool F. D., et al., Dysfunction of the Diaphragm. The New England Journal of Medicine 2012.;366:932-42.


Disorder of Diaphragm – Diaphragmatic Paralysis

Cause for diaphragmatic paralysis or partial paralysis may be due to:¹

RESPIRATORY CONDITIONS

• COPD, asthma and other diseases that cause lung hyperinflation

• Mechanical ventilation

NEUROMUSCULAR CONDITIONS

• Myopathies and neuropathies (e.g. myasthenia gravis, ALS)

• Trauma (e.g. high C-spine injuries involving C3-C5)

• Surgery (phrenic nerve injury)

• Inflammatory disorders (e.g. sepsis)

• Mediastinal masses (e.g. tumor)1https://pulmccm.org/review-articles/diaphragmatic-dysfunction-and-respiratory-illness-review-nejm/

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What’s the Clinical Issue?


Pneumonia – A Common Symptom

• Pneumonia is a chest infection and is an indicator of pulmonary exacerbations and antibiotic use.

• Healthy lungs are constantly producing mucus, as a natural way to keep the lungs clear of infection. Patients with healthy lungs swallow the mucus naturally.

• When a patient has more than one pneumonia in a year, something physiologically has changed in the airway causing that mucus flow to become trapped in the lung, leaving the patient highly susceptible to recurring lung infections (pneumonia).

• Pneumonia may be associated with bronchiectasis OR any of the 52 approved ICD-10 Codes for HFCWO therapy.

• All approved dx for HFCWO leave patients susceptible to pneumonia


Pneumonia and Chronic Lung Disease

• Pneumonia is one of those common lung infections caused by germs, such as bacteria, viruses and fungi.

• The most common type of bacterial pneumonia is called pneumococcal pneumonia and occurs when Streptococcus pneumoniae bacteria spreads from person to person through coughing or close contact.

• When these bacteria reach the lungs, the lungs' air sacs (alveoli) can become inflamed and fill up with mucus.

• While anyone can get pneumococcal pneumonia, individuals with certain chronic medical conditions, such as COPD – which includes emphysema and chronic bronchitis – and asthma are especially at risk for pneumococcal pneumonia.

• For adults 65 or older living with COPD, the risk for contracting pneumococcal pneumonia is 7.7 times higher than their healthy counterparts, and those with asthma are at 5.9 times greater risk

https://www.lung.org/blog/pneumonia-and-lung-disease

/

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Pneumonia and COPD

• People with COPD are more likely to develop pneumonia.

• Pneumonia is particularly dangerous for people with COPD because it causes an increased risk of respiratory failure. This is when the body is either not getting enough oxygen or isn’t successfully removing carbon dioxide.

• Having both pneumonia and COPD can result in serious complications, causing long-term and even permanent damage to the lungs and other major organs.

• The inflammation from the pneumonia can limit airflow, which can further damage the lungs. This can progress into acute respiratory failure, a condition that can be fatal.

https://www.healthline.com/health/copd/copd-and-pneumonia-understanding-your-risk#complications


Pneumonia – What You Need to Know

• Hospital readmission among patients with pneumonia are frequent, costly and potentially avoidable.

• Despite efforts to optimize inpatient care delivery, 30-day readmissions are estimated to occur in 17-25% of patients hospitalized for pneumonia.¹

• Why is a patient having more than 1 pneumonia in a year? What is the root cause?

• Pneumonia is a symptom of bronchiectasis. If a patient is having more than one lung infection in a year, consider screening for bronchiectasis.

• With the correct diagnosis, the patient is eligible for advanced Airway Clearance Therapy as a preventative treatment to maintain lung hygiene and prevent potential hospital re-admissions.

1. www.atsjournals.org

/


Benefits of HFCWO – Advanced ACT

• Effective mucus clearance is essential for pulmonary hygiene and airway disease is often a consequence of poor clearance.

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HFCWO Coverage

Key Chart Note Indicators


Medicare Approved ICD-10 Codes HFCWO (E0483)

A15.0 Tuberculosis of lung B91 Sequelae of poliomyelitis D81.810 Biotinidase deficiency D84.1 Defects in the complement system E84.0 Cystic fibrosis with pulmonary manifestations E84.9 Cystic fibrosis, unspecified G12.0 Infantile spinal muscular atrophy, type I [Werdnig‐Hoffman] G12.1 Other inherited spinal muscular atrophy G12.20 Motor neuron disease, unspecified G12.21 Amyotrophic lateral sclerosis G12.22 Progressive bulbar palsy G12.23 Primary lateral sclerosis G12.24 Familial motor neuron disease G12.25 Progressive spinal muscle atrophy G12.29 Other motor neuron disease G12.8 Other spinal muscular atrophies and related syndromes G12.9 Spinal muscular atrophy, unspecified G14 Postpolio syndrome G35 Multiple sclerosis G71.00 Muscular dystrophy, unspecified G71.01 Duchenne or Becker muscular dystrophy G71.02 Facioscapulohumeral muscular dystrophy G71.09 Other specified muscular dystrophies G71.11 Myotonic muscular dystrophy G71.12 Myotonia congenita G71.13 Myotonic chondrodystrophy

G71.14 Drug induced myotonia G71.19 Other specified myotonic disordersG71.2 Congenital myopathies G71.3 Mitochondrial myopathy, not elsewhere classifiedG71.8 Other primary disorders of muscles G72.0 Drug‐induced myopathy G72.1 Alcoholic myopathy G72.2 Myopathy due to other toxic agents G72.89 Other specified myopathies G73.7 Myopathy in diseases classified elsewhere G82.50 Quadriplegia, unspecified G82.51 Quadriplegia, C1‐C4 complete G82.52 Quadriplegia, C1‐C4 incomplete G82.53 Quadriplegia, C5‐C7 complete G82.54 Quadriplegia, C5‐C7 incomplete J47.0 Bronchiectasis with acute lower respiratory infectionJ47.1 Bronchiectasis with (acute) exacerbationJ47.9 Bronchiectasis, uncomplicatedJ98.6 Disorders of diaphragmM33.02 Juvenile dermatomyositis with myopathy M33.12 Other dermatomyositis with myopathy M33.22 Polymyositis with myopathy M33.92 Dermatopolymyositis, unspecified with myopathy M34.82 Systemic sclerosis with myopathyM35.03 Sicca syndrome with myopathy Q33.4 Congenital bronchiectasis


How Symptoms Tie to Qualifying HFCWO Diagnosis

What if Bronchiectasis is ruled out – now what?

If the CT scan does not confirm BE. Patient may have COPD or other chronic lung disease which are not covered standalone diagnoses. In these cases, if the patient is experiencing airway clearance issues and other treatment options have been attempted and failed, then a physician can look at other diagnoses that may be occurring due to these chronic lung issues (e.g., disorders of the diaphragm, myopathy, etc.).

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How Symptoms Tie to Qualifying HFCWO Diagnosis

If the CT scan does not confirm BE. Patient may have COPD or other chronic lung disease which are not covered standalone diagnoses. In these cases, if the patient is experiencing airway clearance issues and other treatment options have been attempted and failed, then a physician can look at other diagnoses that may be occurring due to these chronic lung issues (e.g., disorders of the diaphragm, myopathy, etc.).


HFCWO – Coverage Criteria

Daily productive (mucus) cough for at least 6 continuous months

ORFrequent (i.e., more than 2/year) exacerbations/chest infections requiring antibiotic therapy

ANDWell‐documented failure of other treatments to adequately mobilize retained secretions/airway clearance

ANDDiagnosis confirmed via a CT scan

HFCWO (E0483) is reimbursed by Medicare, Medicaid, and most private insurance for qualified patients whose medical records document:

Diagnosis

AND

Chart Notes to support the diagnosis

AND

Well‐documented failure of other treatments to adequately mobilize retained secretions/airway clearance

Bronchiectasis Disorders of The Diaphragm, CF and Neuromuscular


HFCWO Reimbursement ConsiderationsWell‐documented failure of other treatments to adequately

mobilize retained secretions/airway clearance

COMMON REASON AIRWAY CLEARANCE TREATMENTS FAILS

• Did not mobilize secretions

• Unable to tolerate positioning (CPT)

• Insufficient expiratory force

• Physical limitations of patient or caregiver

• No caregiver available

• Cognitive level

• Severe arthritis/osteoporosis

COMMON AIRWAY CLEARANCE TREATMENT TRIED, FAILED OR INAPPROPRIATE ‐ EXAMPLES

• Patient tried Chest Physical Therapy (CPT) but was unable to tolerate treatment or has no caregiver available to perform treatment.

• Patient used Flutter/Acapella device, but it did not effectively mobilize secretions.

• Patient has insufficient expiratory force to perform Huff Cough effectively to mobilize secretions.

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Coverage Criteria – Disorders of Diaphragm

In order to ensure coverage of HFCWO therapy under the Disorders of the Diaphragm Diagnosis (J98.6), it is important that the following criteria is met:

• The diagnosis must be clearly defined within in the chart notes and be noted as a part of the patient’s clinical diagnostic history. It is important that the diagnostic history clearly paints a picture of how the patient’s condition has evolved into Disorders of the Diaphragm and has compromised their ability to clear secretions on their own.

• Thorough chart notes indicating that other treatments aimed at mobilizing secretions have been tried and failed or thorough documentation of why other treatments would not be sufficient or are not an option for a specific patient.


Key Chart Indicators for Airway Clearance

Look for the Symptoms that may indicate a need for Airway Clearance:

• Persistent or Chronic Cough

• Productive Cough (associated with bronchiectasis)

• Ineffective Cough (associated with diaphragmatic disfunction)

• Pneumonia

• Pseudomonas Infections in the lung (often associated with bronchiectasis)

• Multiple rounds of ABX to treat lung infections

• Mucus Retention

• Mucus Plugging

• Mucus Hypersecretion

• Hyperinflation of the lungs

• Relaxation of the diaphragm

• Flattening of the diaphragm


Q&A, Discussion

2/18/2021



Thank You!


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