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
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Hypoxic High Altitude Simulation Test (HAST) for Pulmonary Patients Carl Mottram, BA RRT RPFT FAARC Director - Pulmonary Function Labs & Rehabilitation.
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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
• 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.
• 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
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
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
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.
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.
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.
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.
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
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
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]
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]•
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]
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]
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]
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
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
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
High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods
High Altitude Simulation Test High Altitude Simulation Test (HAST)- Methods(HAST)- Methods
• Unaffordable and Unaffordable and impracticalimpractical
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?
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
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
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%
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
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
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High Altitude Simulation
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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%
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%
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
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)
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 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
• 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
• 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.
• 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.