T-Piece System
            Tracheostomy Collar System
            CPAP System

            T-Piece System
            Tracheostomy Collar System
            CPAP System

• Both systems were acknowledged for SBTs in a recent consensus statement on management of patients requiring PMV1.
• Both systems are used for SBTs of increasing duration in PMV patients after a certain reduction in ventilatory support has occurred, e.g., Pressure Support of 10 to 15 cm H2O 1.
• Both systems require removal of the patient from mechanical ventilation to allow self-breathing.
• Both systems allow negative pressure breathing.
• Both systems deliver a humidified air/oxygen mixture.
• Both systems attach directly to the 15mm connector of a tracheal tube.

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• The Cadence™ System is indicated for the treatment of hypoxemia with delivery of transtracheal high flows of a heated and humidified air/oxygen mixture to self-breathing patients with a cuff-deflated fenestrated tracheostomy tube.  It is indicated for hospital use in adult patients.
• The Cadence™ System may improve exercise capacity2,3.
• T-Piece Systems are typically used in adults or children with a tracheostomy tube or endotracheal tube in place.  They may be used as an SBT in PMV patients and those patients requiring more short-term ventilation. 

• The Cadence™ System delivers high flows of an air/oxygen mixture through a catheter that passes directly through the lumen of the tracheostomy tube and in to the distal trachea.
• T-Piece Systems deliver high flows of an air/oxygen mixture horizontally past the tracheostomy tube and in to the atmosphere.

• Transtracheal gas delivery has been shown to reduce inspired3,4 and expired minute ventilation5, to decrease physiologic deadspace6,7, reduce work of breathing3,8 and improve the efficiency of breathing3,5,8 and reduce hyperinflation5.  The magnitude of benefit is greater with higher flows studied.
• Comparison of parallel studies with T-Piece Systems have not been done.  However, controls with only a proportionally increased FIO2 inspired through the upper airway did not show similar benefit.

• The Cadence™ System should only be used with a Portex Blue Line Fenestrated Tracheostomy Tube, size 7, 8 or 9.
• T-Piece Systems may be used with a fenestrated or unfenestrated tracheostomy tube.

• Deflated with the Cadence™ System
• Inflated with T-Piece Systems

• Utilized with the Cadence™ System
• Bypassed with T-Piece Systems

• The Cadence™ System is an open system because, with the cuff deflated, the tracheal lumen communicates with the upper airway. 
• T-Piece Systems are closed systems because, with the cuff inflated, the tracheal lumen does not communicate with the upper airway. 

• The Cadence™ System delivers water vapor using a temperature-controlled servo humidifier with heated wire circuit.  Additional inspired room air is naturally heated and humidified by the upper airway.
• T-Piece Systems deliver water aerosols that may or may not be heated.  Additional room air inspired directly into the trachea through a T-Piece System is neither heated nor humidified.

• The Cadence™ System provides a heated wire circuit.  This allows heating of the flow through the circuit which minimizes condensate.  There is minimal humidity deficit when the gas reaches the trachea.
• T-Piece Systems may be heated or unheated.  If heated, it occurs at the wall outlet.  Depending on the length of corrugated tubing used, the gas cools and condensate occurs before flow reaches the patient.  There can be substantial humidity deficit when the gas reaches the trachea.

• The Cadence™ System uses an air/oxygen blender with backpressure compensated flowmeter to deliver an accurate and known flow directly into the trachea.  The patient is able to receive additional flow to the lungs by drawing in room air through the upper airway using normal negative pressure breathing.
• T-Piece Systems – A backpressure compensated flowmeter connected to a wall oxygen source delivers a known and accurate flow of pure oxygen into a venturi device.  Using Bernoulli’s principle, variable amounts of air are entrained into the system, depending on the selected setting for a desired FIO2.  Lower FIO2 settings deliver higher flows and visa versa.  The flow passing horizontal to the trachea is available for the patient to physically draw into the lungs by negative pressure breathing.  If the patient’s inspiratory flow is greater than the device flow, room air will be drawn into the lungs.  A reservoir device or “afterburner” tubing may reduce room air entrainment.

• The Cadence™ System allows the clinician to set a specific FIO2 that is administered through the catheter directly into the trachea.  Room air inspired through the upper airway dilutes the oxygen enriched gas from the catheter.  Consequently, the actual FIO2 delivered to the lungs is lower than the oxygen concentration set on the Cadence™ System.  The magnitude of reduction of delivered FIO2 over any period of time is related to the volume of air inspired through the upper airway compared to the volume of oxygen enriched gas delivered by the catheter.
• With T-Piece Systems, FIO2 delivered to the lungs over any period of time is dependent upon the volume of oxygen enriched gas inhaled from the T-Piece System, compared to the volume of additional room air inhaled by the patient.  As with the Cadence™ System, the FIO2 delivered to the lungs will be less than the device setting when dilution with inspired room air occurs.

• The Cadence™ System air/oxygen blender allows an oxygen concentration from 21% to 100% to be delivered through the catheter.  A warning label states that the concentration setting should be less than 77% to reduce the risk of oxygen toxicity.
• The oxygen concentration delivered through the tubing of a T-Piece System is variable, based on the venturi device settings of the manufacturer which generally range between about 40% and 100%.  An oxygen concentration of 100% can be delivered if no venturi setting is selected and no air entrainment occurs.  Oxygen concentration should also be limited when possible to reduce the risk of oxygen toxicity.

• The Cadence™ System has a standard 6 foot/15 mm heated wire circuit with a 15 inch Cadence™ Mid-section Hose.
• T-Piece Systems use a variable length of corrugated tubing.  The length of the tubing can affect condensate, temperature and humidity of the gas.  Backpressure from resistance can affect accuracy of the venturi device relative to entrained flow and FIO2.

• The Cadence™ System allows the patient to have a productive cough.  The vocal cords facilitate expulsion of mucus through the upper airway using a normal glottic blast.
• A T-Piece System allows the patient to be suctioned or expectorate secretions through the tracheostomy tube.  Cough is less effective than normal as the vocal cords are bypassed with cuff inflation, consequently, the patient cannot generate a glottic blast.

• The deflated cuff of the Cadence™ System restores airflow past the vocal cords and through the upper airway, allowing the patient to communicate verbally with caregivers
• The inflated cuff of T-Piece Systems does not allow airflow past the vocal cords and through the upper airway.  Consequently, verbal communication does not occur.

• The Cadence™ System utilizes a high pressure alarm as well as a pressure relief valve.
• T-Piece Systems have no pressure alarms.

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• Both systems were acknowledged for SBTs in a recent consensus statement on management of patients requiring PMV1.
• Both systems are used for SBTs of increasing duration in PMV patients after a certain reduction in ventilatory support has occurred (e.g., Pressure Support of 10 to 15 cm H2O) 1.
• Both systems require removal of the patient from mechanical ventilation to allow self-breathing.
• Both systems allow negative pressure breathing.
• Both systems deliver a humidified air/oxygen mixture.

† Top Of Page

• The Cadence™ System is indicated for the treatment of hypoxemia with delivery of transtracheal high flows of a heated and humidified air/oxygen mixture to self-breathing patients with a cuff-deflated fenestrated tracheostomy tube.  It is indicated for hospital use in adult patients.
• The Cadence™ System may improve exercise capacity2,3.
• Tracheostomy Collar (TC) Systems are typically used in adults or children with a tracheostomy tube in place.  They may be used as an SBT in PMV.

• The Cadence™ System delivers high flows of an air/oxygen mixture through a catheter that passes directly through the lumen of the tracheostomy tube and in to the distal trachea.
• TC Systems deliver high flows of an air/oxygen mixture horizontally past the tracheal tube and in to the atmosphere.

• Transtracheal gas delivery has been shown to reduce inspired3,4 and expired minute ventilation5, to decrease physiologic deadspace6,7, reduce work of breathing3,8 and improve the efficiency of breathing3,5,8 and reduce hyperinflation5.  The magnitude of benefit is greater with higher flows studied.
• Comparison of parallel studies with TC Systems has not been done.  However, controls where only a proportionally increased FIO2 inspired through the upper airway did not show similar benefit.

• The Cadence™ System should only be used with a Portex Blue Line Fenestrated Tracheostomy Tube, size 7, 8 or 9.
• TC Systems may be used with a fenestrated or unfenestrated tracheostomy tube.

• The Cadence™ System attaches directly to the 15mm connector of the tracheostomy tube, reducing chances of incorrect positioning of the system.
• A TC System is designed to be seated directly around the 15mm connector of the tracheostomy tube, and is fastened around the neck with a flexible elastic band.  Since it is not directly attached to the tracheostomy tube, displacement of the system is a concern.  Proper TC System delivery will not occur with TC misplacement.

• Deflated with the Cadence™ System
• Inflated with TC Systems

• Utilized with the Cadence™ System
• Bypassed with TC Systems

• The Cadence™ System is an open system because, with the cuff deflated, the tracheal lumen communicates with the upper airway. 
• TC Systems are closed systems because, with the cuff inflated, the tracheal lumen does not communicate with the upper airway. 

• The Cadence™ System delivers water vapor using a temperature-controlled servo humidifier with heated wire circuit.  Additional inspired room air is naturally heated and humidified by the upper airway.
• TC Systems deliver water aerosols that may or may not be heated.  Additional room air inspired directly into the trachea through a TC System is neither heated nor humidified.

• The Cadence™ System provides a heated wire circuit.  This allows heating of the flow through the circuit which minimizes condensate.  There is minimal humidity deficit when the gas reaches the trachea.
• TC Systems may be heated or unheated.  If heated, it occurs at the wall outlet.  Depending on the length of corrugated tubing used, the gas cools and condensate occurs before flow reaches the patient.  There can be substantial humidity deficit when the gas reaches the trachea.

• The Cadence™ System uses an air/oxygen blender with backpressure compensated flowmeter to deliver an accurate and known flow directly into the trachea.  The patient is able to receive additional flow to the lungs by drawing in room air through the upper airway using normal negative pressure breathing.
• TC Systems – A backpressure compensated flowmeter connected to a wall oxygen source delivers a known and accurate flow of pure oxygen into a venturi device.  Using Bernoulli’s principle, variable amounts of air are entrained into the system, depending on the selected setting for a desired FIO2.  Lower FIO2 settings deliver higher flows and visa versa.  The flow passing horizontal to the trachea is available for the patient to physically draw into the lungs by negative pressure breathing.  If the patient’s inspiratory flow is greater than the device flow, room air will be drawn into the lungs.

Delivered FIO2 Mechanism

• The Cadence™ System allows the clinician to set a specific FIO2 that is administered through the catheter directly into the trachea. Room air inspired through the upper airway dilutes the oxygen enriched gas from the catheter.  Consequently, the actual FIO2 delivered to the lungs is lower than the oxygen concentration set on the Cadence™ System.  The magnitude of reduction of delivered FIO2 over any period of time is related to the volume of air inspired through the upper airway compared to the volume of oxygen enriched gas delivered by the catheter.
• With TC Systems, the FIO2 delivered to the lungs over any period of time is dependent upon the volume of oxygen enriched gas inhaled from the TC System compared to the volume of additional room air inhaled by the patient.  As with the Cadence™ System, the FIO2 delivered to the lungs will be less than the device setting when dilution with inspired room air occurs.

Set FIO2 Range

• The Cadence™ System air/oxygen blender allows an oxygen concentration from 21% to 100% to be delivered through the catheter.  A warning label states that the concentration setting should be less than 77% to reduce the risk of oxygen toxicity.
• The oxygen concentration delivered through the tubing of a TC System is variable based on the venturi device settings of the manufacturer which generally range between about 40% and 100%.  An oxygen concentration of 100% can be delivered if no venturi setting is selected and no air entrainment occurs.  Oxygen concentration should also be limited when possible to reduce the risk of oxygen toxicity.

• The Cadence™ System has a standard 6 foot 15 mm heated wire circuit with a 15 inch Cadence™ Mid-Section Hose.
• TC Systems use a variable length of corrugated tubing.  The length of the tubing can affect condensate, temperature and humidity of the gas.  Backpressure from resistance can affect accuracy of the venturi device relative to entrained flow and FIO2.

• The Cadence™ System allows the patient to have a productive cough.  The vocal cords facilitate expulsion of mucus through the upper airway using a normal glottic blast.
• TC System allow the patient to be suctioned or expectorate secretions through the tracheostomy tube.  Cough is less effective than normal as the vocal cords are bypassed with cuff inflation. Consequently, the patient cannot generate a glottic blast.

• The deflated cuff of the Cadence™ System restores airflow past the vocal cords and through the upper airway, allowing the patient to communicate verbally with caregivers.
• The inflated cuff of aTC System does not allow airflow past the vocal cords and through the upper airway.  Consequently, verbal communication does not occur.

• The Cadence™ System utilizes a high pressure alarm as well as a pressure relief valve.
• TC Systems have no pressure alarms.

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• Both systems deliver a humidified air/oxygen mixture.

† Top Of Page

• The Cadence™ System is indicated for the treatment of hypoxemia with delivery of transtracheal high flows of a heated and humidified air/oxygen mixture to self-breathing patients with a cuff-deflated fenestrated tracheostomy tube.  It is indicated for hospital use in adult patients.
• The Cadence™ System may improve exercise capacity2,3.
• CPAP Systems are commonly used as a single mode on positive pressure ventilation in the ICU for SBTs in adults and children requiring short-term ventilation, but they are not commonly used in post-ICU settings for SBTs in PMV patients1. This therapy is presented here for completeness.  CPAP Systems may be use with a tracheostomy tube or endotracheal tube in place.

• The Cadence™ System delivers high flows of an air/oxygen mixture through a catheter that passes directly through the lumen of the tracheostomy tube and in to the distal trachea.
• CPAP Systems deliver an air/oxygen mixture through a tracheostomy tube.

• The Cadence™ System has achievement of specific high flows as a targeted outcome.  Positive pressure is mitigated to allow normal negative pressure breathing.
• CPAP Systems have achievement of specific continuous positive pressure as the outcome, irrespective of flow.

• Transtracheal gas delivery has been shown to reduce inspired3,4 and expired minute ventilation5, to decrease physiologic deadspace6,7, reduce work of breathing3,8 and improve the efficiency of breathing3,5,8 and reduce hyperinflation5.  The magnitude of benefit is greater with higher flows studied.
• Comparison of parallel studies with CPAP Systems has not been done.  The basic assumption of using low levels of CPAP in SBTs for short-term ventilation, e.g., 5cm H2O, is that the pressure overcomes the resistance of a tracheal tube, particularly an endotracheal tube.

• The Cadence™ System should only be used with a Portex Blue Line Fenestrated Tracheostomy Tube, size 7, 8 or 9.
• CPAP Systems can be used with an unfenestrated tracheostomy tube.

• Deflated with the Cadence™ System.
• Inflated with CPAP Systems.

• Utilized with the Cadence™ System.
• Bypassed with CPAP Systems.

• The Cadence™ System is an open system because, with the cuff deflated, the tracheal lumen communicates with the upper airway. 
• CPAP Systems are a closed system because, with the cuff inflated, the tracheal lumen does not communicate with the upper airway. 

• The Cadence™ System delivers water vapor using a temperature-controlled servo humidifier with heated wire circuit.  Additional inspired room air is naturally heated and humidified by the upper airway.
• CPAP Systems deliver water vapor using the humidification system of the ventilator.

• The Cadence™ System provides a heated wire circuit.  This allows heating of the flow through the circuit which minimizes condensate.  There is minimal humidity deficit when the gas reaches the trachea.
• CPAP Systems deliver water vapor using the humidification system of the ventilator.

• The Cadence™ System uses an air/oxygen blender with backpressure compensated flowmeter to deliver an accurate and known flow directly into the trachea.  The patient is able to receive additional flow to the lungs by drawing in room air through the upper airway using normal negative pressure breathing.
• CPAP Systems have pressure as the targeted outcome.  Flow is administered to achieve desired pressure.

• The Cadence™ System allows the clinician to set a specific FIO2 that is administered through the catheter directly into the trachea.  Room air inspired through the upper airway dilutes the oxygen enriched gas from the catheter.  Consequently, the actual FIO2 delivered to the lungs is lower than the oxygen concentration set on the Cadence™ System.  The magnitude of reduction of delivered FIO2 over any period of time is related to the volume of air inspired through the upper airway compared to the volume of oxygen enriched gas delivered by the catheter.
• CPAP Systems - The FIO2 is determined by the ventilator settings in this closed system.

• The Cadence™ System air/oxygen blender allows an oxygen concentration from 21% to 100% to be delivered through the catheter.  A warning label states that the concentration setting should be less than 77% to reduce the risk of oxygen toxicity.
• With CPAP Systems, the FIO2 can be selected in increments between 21% and 100%.  Oxygen concentration should also be limited when possible to reduce the risk of oxygen toxicity

• The Cadence™ System has a standard 6 foot, 15 mm heated wire circuit with a 15 inch Cadence™ Mid-Section Hose.
• A CPAP System’s circuit length is determined by the circuit required for the particular ventilator.

• The Cadence™ System allows the patient to have a productive cough.  The vocal cords facilitate expulsion of mucus through the upper airway using a normal glottic blast.
• CPAP Systems allow the patient to be suctioned or expectorate secretions through the tracheostomy tube and breathing circuit.  Cough is less effective than normal as the vocal cords are bypassed with cuff inflation.  Consequently, the patient cannot generate a glottic blast.

• The deflated cuff of the Cadence™ System restores airflow past the vocal cords and through the upper airway, allowing the patient to communicate verbally with the caregivers.
• The inflated cuff of a CPAP System does not allow airflow past the vocal cords and through the upper airway.  Consequently, verbal communication does not occur.

• The Cadence™ System utilizes a high pressure alarm as well as a pressure relief valve.
• CPAP Systems have pressure alarms and relief valve incorporated in to the ventilator.

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References

1. MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S.  Consensus statement:  Management of patients requiring prolonged mechanical ventilation. Chest 2005;128:3937-3954.
2. Dewan NA, Bell CW.  Effect of low flow and high flow oxygen delivery on exercise tolerance and sensation of dyspnea.  A study comparing the transtracheal catheter and nasal prongs.  Chest 1994;105(4):1061-5.
3. Christopher KL, VanHooser DT, Jorgenson ST, Winslett L, Diehl S, Young DA, Shapiro H. Petty TL,  Preliminary observations of transtracheal augmented ventilation for chronic severe respiratory disease. Respir Care 2001;46:15-25.
4. Couser JI, Make BJ.  Transtracheal oxygen decreases inspired minute ventilation.  Am Rev Respir Dis 1989;139:627-31.
5. Brack T, Senn O, Russi EW, Bloch KE.  Transtracheal high flow insufflation supports spontaneous respiration in chronic respiratory failure.  Chest 2005;127:98-104.
6. Bergofsky EH, Hurewitz AN.  Airway insufflation:  physiologic effects on acute and chronic gas exchange in humans.  Am Rev Respir Dis 1989;140:885-90.
7. Hurewitz AN, Bergofsky EH, Vomero E.  Airway insufflation - increasing flow rates progressively reduce dead space in respiratory failure.  Am Rev Respir Dis 1991;144:1229-33.
8. Benditt J, Pollock M, Roa J, Celli B.  Transtracheal delivery of gas decreases the oxygen cost of breathing.  Am Rev Respir Dis 1993;147:1207-10.

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