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Hypoxic High Altitude Simulation Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Director - Pulmonary Function Labs & Rehabilitation Rehabilitation Assistant Professor of Medicine - Mayo Assistant Professor of Medicine - Mayo Clinic College of Medicine Clinic College of Medicine

Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

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Page 1: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

Hypoxic High Altitude Simulation Hypoxic High Altitude Simulation Test (HAST) for Pulmonary PatientsTest (HAST) for Pulmonary PatientsHypoxic High Altitude Simulation Hypoxic High Altitude Simulation

Test (HAST) for Pulmonary PatientsTest (HAST) for Pulmonary Patients

Carl Mottram, BA RRT RPFT FAARCCarl Mottram, BA RRT RPFT FAARCDirector - Pulmonary Function Labs & RehabilitationDirector - Pulmonary Function Labs & Rehabilitation

Assistant Professor of Medicine - Mayo Clinic College of Assistant Professor of Medicine - Mayo Clinic College of MedicineMedicine

Carl Mottram, BA RRT RPFT FAARCCarl Mottram, BA RRT RPFT FAARCDirector - Pulmonary Function Labs & RehabilitationDirector - Pulmonary Function Labs & Rehabilitation

Assistant Professor of Medicine - Mayo Clinic College of Assistant Professor of Medicine - Mayo Clinic College of MedicineMedicine

Page 2: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

Background: In-Flight RegulationsBackground: In-Flight RegulationsBackground: In-Flight RegulationsBackground: In-Flight Regulations

• Standard for airline cabin Standard for airline cabin pressurization is regulated by the FAA.pressurization is regulated by the FAA.

• (SAE ARP1270) (SAE ARP1270)

• The most important factor in this The most important factor in this standard is that cabin altitude pressure standard is that cabin altitude pressure not exceed more than 8000 ft. altitude not exceed more than 8000 ft. altitude in normal conditions. in normal conditions.

• Standard for airline cabin Standard for airline cabin pressurization is regulated by the FAA.pressurization is regulated by the FAA.

• (SAE ARP1270) (SAE ARP1270)

• The most important factor in this The most important factor in this standard is that cabin altitude pressure standard is that cabin altitude pressure not exceed more than 8000 ft. altitude not exceed more than 8000 ft. altitude in normal conditions. in normal conditions.

Page 3: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

Background: In-Flight RegulationsBackground: In-Flight RegulationsBackground: In-Flight RegulationsBackground: In-Flight Regulations

• The FAA allows for brief drops in air The FAA allows for brief drops in air pressure for safety purposes only, such pressure for safety purposes only, such as to avoid bad weather conditions. The as to avoid bad weather conditions. The minimum air pressure is equal to minimum air pressure is equal to 10,000 ft. 10,000 ft.

• Average 6214 ft (range 0 – 8915 ft) Average 6214 ft (range 0 – 8915 ft) • Cottrell JJ Chest 1988 (92) 81-4Cottrell JJ Chest 1988 (92) 81-4

• The FAA allows for brief drops in air The FAA allows for brief drops in air pressure for safety purposes only, such pressure for safety purposes only, such as to avoid bad weather conditions. The as to avoid bad weather conditions. The minimum air pressure is equal to minimum air pressure is equal to 10,000 ft. 10,000 ft.

• Average 6214 ft (range 0 – 8915 ft) Average 6214 ft (range 0 – 8915 ft) • Cottrell JJ Chest 1988 (92) 81-4Cottrell JJ Chest 1988 (92) 81-4

Page 4: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

Cramer D. Ward S. Geddes D. Assessment of oxygen supplementation during air travel. Thorax. 51(2):202-3, 1996 Feb.

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) for Pulmonary Patients - Evidencefor Pulmonary Patients - Evidence

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) for Pulmonary Patients - Evidencefor Pulmonary Patients - Evidence

• A. Normal subjectsA. Normal subjects

• B. Subjects with B. Subjects with COPDCOPD

• Subjects with Subjects with restrictive lung dzrestrictive lung dz

• A. Normal subjectsA. Normal subjects

• B. Subjects with B. Subjects with COPDCOPD

• Subjects with Subjects with restrictive lung dzrestrictive lung dz

Page 5: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) for Pulmonary Patients - Evidencefor Pulmonary Patients - Evidence

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) for Pulmonary Patients - Evidencefor Pulmonary Patients - Evidence

• SpO2 measured with 4 L and following 5 min at FIO2 .21 in 3 pts with COPD

•Kramer et. al. Chest, Volume 108(5).November 1995.1292-1296

• SpO2 measured with 4 L and following 5 min at FIO2 .21 in 3 pts with COPD

•Kramer et. al. Chest, Volume 108(5).November 1995.1292-1296

Page 6: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) for Pulmonary Patients - Evidencefor Pulmonary Patients - Evidence

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) for Pulmonary Patients - Evidencefor Pulmonary Patients - Evidence

• 18 retired servicemen (age 68 +/- 6) with severe 18 retired servicemen (age 68 +/- 6) with severe COPD (FEV1 31% +/- 10%) COPD (FEV1 31% +/- 10%)

• Altitude simulation 8000 ft. in a hypobaric chamber. Altitude simulation 8000 ft. in a hypobaric chamber.

• PaOPaO2G2G at sea level of 72.4 +/- 9 mm Hg, PaO at sea level of 72.4 +/- 9 mm Hg, PaO2Alt2Alt of of 47.4 +/- 6 mm Hg after 45 minutes of hypobaric 47.4 +/- 6 mm Hg after 45 minutes of hypobaric exposure.exposure.

• PaOPaO2Alt2Alt = 0.453 [PaO = 0.453 [PaO2G2G] + 0.386 [FEV1% predicted] ] + 0.386 [FEV1% predicted] + 2.440 (r = 0.847)+ 2.440 (r = 0.847)

Annals of Internal Medicine. 111(5):362-7, 1989 Sep 1.Annals of Internal Medicine. 111(5):362-7, 1989 Sep 1.

• 18 retired servicemen (age 68 +/- 6) with severe 18 retired servicemen (age 68 +/- 6) with severe COPD (FEV1 31% +/- 10%) COPD (FEV1 31% +/- 10%)

• Altitude simulation 8000 ft. in a hypobaric chamber. Altitude simulation 8000 ft. in a hypobaric chamber.

• PaOPaO2G2G at sea level of 72.4 +/- 9 mm Hg, PaO at sea level of 72.4 +/- 9 mm Hg, PaO2Alt2Alt of of 47.4 +/- 6 mm Hg after 45 minutes of hypobaric 47.4 +/- 6 mm Hg after 45 minutes of hypobaric exposure.exposure.

• PaOPaO2Alt2Alt = 0.453 [PaO = 0.453 [PaO2G2G] + 0.386 [FEV1% predicted] ] + 0.386 [FEV1% predicted] + 2.440 (r = 0.847)+ 2.440 (r = 0.847)

Annals of Internal Medicine. 111(5):362-7, 1989 Sep 1.Annals of Internal Medicine. 111(5):362-7, 1989 Sep 1.

Page 7: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) for Pulmonary Patients - Evidencefor Pulmonary Patients - Evidence

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) for Pulmonary Patients - Evidencefor Pulmonary Patients - Evidence

• Surveyed physicians Surveyed physicians in Englandin England

• 268 respondents268 respondents

• No consensus exists regarding assessment methods or criteria for recommending oxygen

•R.K. Coker, M.R. Partridge. Eur Respir J 2000; 15: 128±130

• Surveyed physicians Surveyed physicians in Englandin England

• 268 respondents268 respondents

• No consensus exists regarding assessment methods or criteria for recommending oxygen

•R.K. Coker, M.R. Partridge. Eur Respir J 2000; 15: 128±130

Page 8: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) GuidelinesGuidelines

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) GuidelinesGuidelines

• Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations - Evidence Based

• Thorax 2002;57:289–304

Purpose of recommendations (6)

• To enhance safety for passengers with lung disease traveling by air and reduce the number of in-flight medical incidents due to respiratory disease.

• Managing passengers with respiratory disease planning air travel: British Thoracic Society recommendations - Evidence Based

• Thorax 2002;57:289–304

Purpose of recommendations (6)

• To enhance safety for passengers with lung disease traveling by air and reduce the number of in-flight medical incidents due to respiratory disease.

Page 9: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

• To increase recognition among healthcare professionals that patients with respiratory disease may require clinical assessment and advice before air travel.

• To provide an authoritative up to date literature review of available evidence.

• To increase recognition among healthcare professionals that patients with respiratory disease may require clinical assessment and advice before air travel.

• To provide an authoritative up to date literature review of available evidence.

Page 10: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

• To provide consistent, practical, and comprehensive advice for healthcare professionals managing such patients.

• To formulate key research questions

• To promote the development of methods for monitoring the size of the problem

• To provide consistent, practical, and comprehensive advice for healthcare professionals managing such patients.

• To formulate key research questions

• To promote the development of methods for monitoring the size of the problem

Page 11: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

• Evidence definitionsEvidence definitions• Evidence definitionsEvidence definitions

Page 12: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

Ten Indications

• Severe COPD or asthma; [B]

• Severe restrictive disease (including chest wall and respiratory muscle disease), especially with hypoxemia and/or hypercapnia; [C]

Ten Indications

• Severe COPD or asthma; [B]

• Severe restrictive disease (including chest wall and respiratory muscle disease), especially with hypoxemia and/or hypercapnia; [C]

Page 13: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

• Patients with cystic fibrosis; [C]

• History of air travel intolerance with respiratory symptoms (dyspnea, chest pain, confusion or syncope); [C]

• Co-morbidity with other conditions worsened by hypoxemia (cerebrovascular disease, coronary artery disease, heart failure); [C]•

• Patients with cystic fibrosis; [C]

• History of air travel intolerance with respiratory symptoms (dyspnea, chest pain, confusion or syncope); [C]

• Co-morbidity with other conditions worsened by hypoxemia (cerebrovascular disease, coronary artery disease, heart failure); [C]•

Page 14: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

• Pulmonary tuberculosis; [C]

• Within 6 weeks of hospital discharge for acute respiratory illness; [C]

• Recent pneumothorax; [B]

• Risk of or previous venous thromboembolism; [B]

• Pre-existing requirement for oxygen or ventilator support. [C]

• Pulmonary tuberculosis; [C]

• Within 6 weeks of hospital discharge for acute respiratory illness; [C]

• Recent pneumothorax; [B]

• Risk of or previous venous thromboembolism; [B]

• Pre-existing requirement for oxygen or ventilator support. [C]

Page 15: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

Recommended assessment

• History and examination with particular reference to cardiorespiratory disease, dyspnea, and previous flying experience; [C]

• Spirometry [C]

• SpO2 by pulse oximetry or ABG’s [C]

Recommended assessment

• History and examination with particular reference to cardiorespiratory disease, dyspnea, and previous flying experience; [C]

• Spirometry [C]

• SpO2 by pulse oximetry or ABG’s [C]

Page 16: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

• Blood gas tensions are preferred if hypercapnia is known or suspected. [C]

• In those who are screened who have resting sea level oximetry between 92% and 95% with additional risk factors, hypoxic challenge testing is recommended [C]

• Blood gas tensions are preferred if hypercapnia is known or suspected. [C]

• In those who are screened who have resting sea level oximetry between 92% and 95% with additional risk factors, hypoxic challenge testing is recommended [C]

Page 17: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

Page 18: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

High Altitude Simulation Test (HAST) High Altitude Simulation Test (HAST) BTS Guidelines BTS Guidelines

Page 19: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test (HAST)High Altitude Simulation Test (HAST)High Altitude Simulation Test (HAST)High Altitude Simulation Test (HAST)

• Gong H. at el coined the term Hypoxic Gong H. at el coined the term Hypoxic Altitude Simulation Test (1984) Altitude Simulation Test (1984)

• Premise: Altitude hypoxia is a primary Premise: Altitude hypoxia is a primary stress or threat to patients with stress or threat to patients with cardiopulmonary disorders and FIOcardiopulmonary disorders and FIO22 at at altitude can be replicated according to altitude can be replicated according to known pressure-altitude relationshipsknown pressure-altitude relationships

• Monitored SpOMonitored SpO22 and ECG and ECG

• Gong H. at el coined the term Hypoxic Gong H. at el coined the term Hypoxic Altitude Simulation Test (1984) Altitude Simulation Test (1984)

• Premise: Altitude hypoxia is a primary Premise: Altitude hypoxia is a primary stress or threat to patients with stress or threat to patients with cardiopulmonary disorders and FIOcardiopulmonary disorders and FIO22 at at altitude can be replicated according to altitude can be replicated according to known pressure-altitude relationshipsknown pressure-altitude relationships

• Monitored SpOMonitored SpO22 and ECG and ECG

Page 20: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

• Ideal test: Ideal test: Hypobaric chamberHypobaric chamber

• Variable altitudesVariable altitudes

• Oxygen titrationOxygen titration

• Unaffordable and Unaffordable and impracticalimpractical

• Ideal test: Ideal test: Hypobaric chamberHypobaric chamber

• Variable altitudesVariable altitudes

• Oxygen titrationOxygen titration

• Unaffordable and Unaffordable and impracticalimpractical

Page 21: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

• Modified body Modified body plethysmographplethysmograph

• Exit port for gas Exit port for gas flowflow

• Controlled Controlled environmentenvironment

• Oxygen titration?Oxygen titration?

• Modified body Modified body plethysmographplethysmograph

• Exit port for gas Exit port for gas flowflow

• Controlled Controlled environmentenvironment

• Oxygen titration?Oxygen titration?

Page 22: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

• Standard gas mixture Standard gas mixture cylindercylinder

• Directional valveDirectional valve

• Demand valveDemand valve

• Standard gas mixture Standard gas mixture cylindercylinder

• Directional valveDirectional valve

• Demand valveDemand valve

Page 23: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

• Blender driven with Blender driven with 100% N100% N22 and .21 and .21

•Variable FIOVariable FIO22

• Oxygen analyzerOxygen analyzer

• ReservoirReservoir

• Directional valve Directional valve

• CPAP maskCPAP mask

• Blender driven with Blender driven with 100% N100% N22 and .21 and .21

•Variable FIOVariable FIO22

• Oxygen analyzerOxygen analyzer

• ReservoirReservoir

• Directional valve Directional valve

• CPAP maskCPAP mask

Page 24: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

• Non-rebreathing maskNon-rebreathing mask•Gas source Gas source

• Venti-maskVenti-mask•Driven with 100% Driven with 100% nitrogen 40% setting = nitrogen 40% setting = approximately 14-15%approximately 14-15%•Set to 35% = Set to 35% = approximately 15-16%approximately 15-16%

• Non-rebreathing maskNon-rebreathing mask•Gas source Gas source

• Venti-maskVenti-mask•Driven with 100% Driven with 100% nitrogen 40% setting = nitrogen 40% setting = approximately 14-15%approximately 14-15%•Set to 35% = Set to 35% = approximately 15-16%approximately 15-16%

Page 25: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

• Alternative altitudesAlternative altitudes•Bengdag, China: 14,100 ft•Bogota, Colomba: 8355 ft•Quito, Ecuador: 9222 ft•Telluride, USA: 9086 ft

• Alternative altitudesAlternative altitudes•Bengdag, China: 14,100 ft•Bogota, Colomba: 8355 ft•Quito, Ecuador: 9222 ft•Telluride, USA: 9086 ft

• Alternative Indications•Athletic training

• Alternative Indications•Athletic training

Page 26: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

• Determining the standard gas mixture at your Determining the standard gas mixture at your altitude or for varying altitudesaltitude or for varying altitudes

• Factor = [1-6.873E-6 X Alt(Feet)]^5.256Factor = [1-6.873E-6 X Alt(Feet)]^5.256

• Bag FIO2 = ((760 X factor)/PBaro) X 0.21 Bag FIO2 = ((760 X factor)/PBaro) X 0.21

• Determining the standard gas mixture at your Determining the standard gas mixture at your altitude or for varying altitudesaltitude or for varying altitudes

• Factor = [1-6.873E-6 X Alt(Feet)]^5.256Factor = [1-6.873E-6 X Alt(Feet)]^5.256

• Bag FIO2 = ((760 X factor)/PBaro) X 0.21 Bag FIO2 = ((760 X factor)/PBaro) X 0.21 High Altitude Simulation

0

0.05

0.1

0.15

0.2

0.25

0 2000 4000 6000 8000 10000 12000

Altitude

Insp

ired

Oxyg

en

Co

ncen

trati

on

Series1

High Altitude Simulation

0

0.05

0.1

0.15

0.2

0.25

0 2000 4000 6000 8000 10000 12000

Altitude

Insp

ired

Oxyg

en

Co

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Series1

Page 27: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

• Rochester, MN average barometric Rochester, MN average barometric pressure = 740 mmHgpressure = 740 mmHg

• Standard gas mixture for 8000 ft is Standard gas mixture for 8000 ft is 16.1% 16.1%

• Denver = 5,280 ft (“Denver = 5,280 ft (“mile high city”)mile high city”)• Bag FIO2 = ((760 X factor)/PBaro) X 0.21Bag FIO2 = ((760 X factor)/PBaro) X 0.21• Bag FIO2 = ((760 X .82495)/740) X 0.21Bag FIO2 = ((760 X .82495)/740) X 0.21• Bag FIO2 = 17.8%Bag FIO2 = 17.8%

• Rochester, MN average barometric Rochester, MN average barometric pressure = 740 mmHgpressure = 740 mmHg

• Standard gas mixture for 8000 ft is Standard gas mixture for 8000 ft is 16.1% 16.1%

• Denver = 5,280 ft (“Denver = 5,280 ft (“mile high city”)mile high city”)• Bag FIO2 = ((760 X factor)/PBaro) X 0.21Bag FIO2 = ((760 X factor)/PBaro) X 0.21• Bag FIO2 = ((760 X .82495)/740) X 0.21Bag FIO2 = ((760 X .82495)/740) X 0.21• Bag FIO2 = 17.8%Bag FIO2 = 17.8%

Page 28: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

• Walking Walking •BTS recommends walking if SaOBTS recommends walking if SaO22 87-90% 87-90%

• OO22 Titration Titration•HypobaricHypobaric chamberchamber•Body boxBody box•Mask???Mask???

• Walking Walking •BTS recommends walking if SaOBTS recommends walking if SaO22 87-90% 87-90%

• OO22 Titration Titration•HypobaricHypobaric chamberchamber•Body boxBody box•Mask???Mask???

Page 29: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods

• BTS Guidelines – oxygen BTS Guidelines – oxygen recommendationsrecommendations

• Guideline threshold for advising in-flight oxygen: 82–84%

• 2 l/min via nasal cannula will improve hypoxemia but not quite to sea level values

• 4 l/min > sea level values

• BTS Guidelines – oxygen BTS Guidelines – oxygen recommendationsrecommendations

• Guideline threshold for advising in-flight oxygen: 82–84%

• 2 l/min via nasal cannula will improve hypoxemia but not quite to sea level values

• 4 l/min > sea level values

Page 30: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation
Page 31: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Equipment(HAST)- Equipment

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Equipment(HAST)- Equipment

• Hypoxia gas delivery system Hypoxia gas delivery system and appropriate mixtureand appropriate mixture

• Electrocardiograph and blood Electrocardiograph and blood pressure systempressure system

• Ratings of Perceived Exertion Ratings of Perceived Exertion scale (RPE)scale (RPE)

• Pulse Oximeter or ABG’sPulse Oximeter or ABG’s

• Hypoxia gas delivery system Hypoxia gas delivery system and appropriate mixtureand appropriate mixture

• Electrocardiograph and blood Electrocardiograph and blood pressure systempressure system

• Ratings of Perceived Exertion Ratings of Perceived Exertion scale (RPE)scale (RPE)

• Pulse Oximeter or ABG’sPulse Oximeter or ABG’s

Page 32: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Protocol(HAST)- Protocol

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Protocol(HAST)- Protocol

• Obtain resting room air variablesObtain resting room air variables• ECG, RPE, B/P, SpOECG, RPE, B/P, SpO22

• Place on hypoxic mixture for 20 Place on hypoxic mixture for 20 minutes or early termination criteria minutes or early termination criteria

• Obtain hypoxic gas mixture variablesObtain hypoxic gas mixture variables• ECG, RPE, B/P, SpOECG, RPE, B/P, SpO22/ABG’s/ABG’s

• Obtain resting room air variablesObtain resting room air variables• ECG, RPE, B/P, SpOECG, RPE, B/P, SpO22

• Place on hypoxic mixture for 20 Place on hypoxic mixture for 20 minutes or early termination criteria minutes or early termination criteria

• Obtain hypoxic gas mixture variablesObtain hypoxic gas mixture variables• ECG, RPE, B/P, SpOECG, RPE, B/P, SpO22/ABG’s/ABG’s

Page 33: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Protocol(HAST)- Protocol

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Protocol(HAST)- Protocol

• Early termination criteriaEarly termination criteria• Change in baseline rhythm (i.e. VT, Change in baseline rhythm (i.e. VT,

SVT, PSVT)SVT, PSVT)• ST – T wave depression > 1 mmST – T wave depression > 1 mm

• SpOSpO22 << 80% 80% • Subject intoleranceSubject intolerance

• Early termination criteriaEarly termination criteria• Change in baseline rhythm (i.e. VT, Change in baseline rhythm (i.e. VT,

SVT, PSVT)SVT, PSVT)• ST – T wave depression > 1 mmST – T wave depression > 1 mm

• SpOSpO22 << 80% 80% • Subject intoleranceSubject intolerance

Page 34: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Reporting(HAST)- Reporting

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Reporting(HAST)- Reporting

Page 35: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Reimbursement(HAST)- Reimbursement

High Altitude Simulation Test High Altitude Simulation Test (HAST)- Reimbursement(HAST)- Reimbursement

“Show me the Money”

Page 36: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation TestHigh Altitude Simulation Test Current Procedural Terminology (CPT) Current Procedural Terminology (CPT)

High Altitude Simulation TestHigh Altitude Simulation Test Current Procedural Terminology (CPT) Current Procedural Terminology (CPT)

• 94452: High Altitude Simulation Test 94452: High Altitude Simulation Test (HAST), with physician interpretation (HAST), with physician interpretation and reportand report

• 94453: High Altitude Simulation Test 94453: High Altitude Simulation Test (HAST), with physician interpretation (HAST), with physician interpretation and report; with supplemental oxygen and report; with supplemental oxygen titration. titration.

• Effective date 01/01/2005Effective date 01/01/2005

• 94452: High Altitude Simulation Test 94452: High Altitude Simulation Test (HAST), with physician interpretation (HAST), with physician interpretation and reportand report

• 94453: High Altitude Simulation Test 94453: High Altitude Simulation Test (HAST), with physician interpretation (HAST), with physician interpretation and report; with supplemental oxygen and report; with supplemental oxygen titration. titration.

• Effective date 01/01/2005Effective date 01/01/2005

Page 37: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation TestHigh Altitude Simulation Test Current Procedural Terminology (CPT)Current Procedural Terminology (CPT)

High Altitude Simulation TestHigh Altitude Simulation Test Current Procedural Terminology (CPT)Current Procedural Terminology (CPT)

Page 38: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

High Altitude Simulation TestHigh Altitude Simulation Test Current Procedural Terminology (CPT)Current Procedural Terminology (CPT)

High Altitude Simulation TestHigh Altitude Simulation Test Current Procedural Terminology (CPT)Current Procedural Terminology (CPT)

• Medicare fee schedule (Minnesota Medicare fee schedule (Minnesota region)region)

• 94452: High Altitude Simulation Test94452: High Altitude Simulation Test• $55.33$55.33

• 94453: High Altitude Simulation Test 94453: High Altitude Simulation Test with supplemental oxygen titrationwith supplemental oxygen titration• $79.13 $79.13

• 93041: ECG rhythm tracing93041: ECG rhythm tracing• $23.66$23.66

• Medicare fee schedule (Minnesota Medicare fee schedule (Minnesota region)region)

• 94452: High Altitude Simulation Test94452: High Altitude Simulation Test• $55.33$55.33

• 94453: High Altitude Simulation Test 94453: High Altitude Simulation Test with supplemental oxygen titrationwith supplemental oxygen titration• $79.13 $79.13

• 93041: ECG rhythm tracing93041: ECG rhythm tracing• $23.66$23.66

Page 39: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

Ambulatory Payment Classification Ambulatory Payment Classification (APC) Code: 00368(APC) Code: 00368

Ambulatory Payment Classification Ambulatory Payment Classification (APC) Code: 00368(APC) Code: 00368

Page 40: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

Air Travel with Oxygen Air Travel with Oxygen Air Travel with Oxygen Air Travel with Oxygen

• Does your airline accept passengers who Does your airline accept passengers who require supplemental oxygen? require supplemental oxygen?

• How much notice do you require before How much notice do you require before the flight? the flight?

• What documentation is required from my What documentation is required from my doctor? doctor?

• What do you charge for supplying oxygen What do you charge for supplying oxygen and how is the charge determined? and how is the charge determined?

• Does your airline accept passengers who Does your airline accept passengers who require supplemental oxygen? require supplemental oxygen?

• How much notice do you require before How much notice do you require before the flight? the flight?

• What documentation is required from my What documentation is required from my doctor? doctor?

• What do you charge for supplying oxygen What do you charge for supplying oxygen and how is the charge determined? and how is the charge determined?

Page 41: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

Air Travel with OxygenAir Travel with OxygenAir Travel with OxygenAir Travel with Oxygen

• Do you allow passengers to bring their Do you allow passengers to bring their empty oxygen equipment? empty oxygen equipment?

• Are there specific seat requirements? Are there specific seat requirements?

• What liter flow options are available? What liter flow options are available?

• Do you provide nasal cannulas or Do you provide nasal cannulas or masks? masks?

• Do you allow passengers to bring their Do you allow passengers to bring their empty oxygen equipment? empty oxygen equipment?

• Are there specific seat requirements? Are there specific seat requirements?

• What liter flow options are available? What liter flow options are available?

• Do you provide nasal cannulas or Do you provide nasal cannulas or masks? masks?

Page 42: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

Air Travel with OxygenAir Travel with OxygenAir Travel with OxygenAir Travel with Oxygen

What to check once you’re on board?What to check once you’re on board?

• Oxygen cylinders are full Oxygen cylinders are full

• The oxygen equipment is working The oxygen equipment is working properly properly

• The flow meter has been set to the The flow meter has been set to the proper liter flow per minute proper liter flow per minute

• You have access to all of your You have access to all of your medicines, including inhalersmedicines, including inhalers

What to check once you’re on board?What to check once you’re on board?

• Oxygen cylinders are full Oxygen cylinders are full

• The oxygen equipment is working The oxygen equipment is working properly properly

• The flow meter has been set to the The flow meter has been set to the proper liter flow per minute proper liter flow per minute

• You have access to all of your You have access to all of your medicines, including inhalersmedicines, including inhalers

Page 43: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

Professor, my brain is full. Can we stop now?

Page 44: Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation

Background: In-Flight RegulationsBackground: In-Flight RegulationsBackground: In-Flight RegulationsBackground: In-Flight Regulations

• The Air Carrier Access Act of 1986 The Air Carrier Access Act of 1986 required the U.S. Department of required the U.S. Department of Transportation to develop regulations Transportation to develop regulations to ensure that persons with disabilities to ensure that persons with disabilities are treated without discrimination in are treated without discrimination in any way, consistent with the safe any way, consistent with the safe carriage of all passengers. carriage of all passengers.

• Air Carrier Access Act, 49 USC §41705 (1986).Air Carrier Access Act, 49 USC §41705 (1986).

• The Air Carrier Access Act of 1986 The Air Carrier Access Act of 1986 required the U.S. Department of required the U.S. Department of Transportation to develop regulations Transportation to develop regulations to ensure that persons with disabilities to ensure that persons with disabilities are treated without discrimination in are treated without discrimination in any way, consistent with the safe any way, consistent with the safe carriage of all passengers. carriage of all passengers.

• Air Carrier Access Act, 49 USC §41705 (1986).Air Carrier Access Act, 49 USC §41705 (1986).