Publication[ edit ] The initial idea for the character of Azrael stemmed from a two-part story idea pitched by Detective Comics writer Peter Milligan circaas he was leaving that position. The massive story was quickly collected into two volumes of trade paperbacks. Knightfall was the first time that multiple Batman titles had shared a single narrative for an extended period since Crisis on Infinite Earths. The Search" and the other on the new Batman "Knightquest:
Post-polio Quadriplegia regardless of underlying etiology. Aetna considers high-frequency chest compression systems experimental and investigational for other indications e.
Aetna considers mechanical in-exsufflation devices medically necessary DME for persons with a neuromuscular disease e.
Aetna considers continuous high-frequency oscillation therapy for the treatment of secretion-induced atelectasis experimental and investigational because there is insufficient evidence supporting its effectiveness. Background Cystic fibrosis CFchronic bronchitis, bronchiectasis, immotile cilia syndrome, asthma, and some acute respiratory tract infections can lead to abnormal airway clearance or increase sputum production.
Airway secretions are cleared by mucociliary clearance MCCin addition to other mechanisms such as cough, peristalsis, two-phase gas-liquid flow and alveolar clearance. The underlying pathology of abnormal airway clearance differs from one illness to another.
Chest physiotherapy CPT is a treatment program that attempts to compensate for abnormal airway clearance. By removing mucopurulent secretions, it decreases airway obstruction and its consequences, such as atelectasis and hyperinflation; furthermore, physiotherapy can decrease the rate of proteolytic tissue damage by removing infected secretions.
Methods to improve removal of tenacious lung secretions in patients with CF contribute to slowing the decline in respiratory function. The standard dependent method of pulmonary care remains clapping, vibration and compression, together with postural drainage and assisted coughing.
Respiratory therapists can teach family members or other informal caregivers to competently administer manual CPT to children and others who are incapable of doing it for themselves. At the same time, the chest or back is clapped percussed and vibrated to dislodge the mucus and help it move out of the airways.
This process is repeated over different parts of the chest and back to loosen the mucus in different areas of each lung. This procedure has to be done for children by family members but older patients can learn to do it by themselves. Mechanical aids that help chest physical therapy are available commercially.
When a competent care giver is not available to administer CPT manually, specific alternative methods may be utilized. Many of these techniques have been developed and studied using CF patients.
De Boeck and colleagues noted that airway clearance techniques are an important part of the respiratory management in children with CF, bronchiectasis and neuromuscular disease.
They are also, however, frequently prescribed in previously healthy children with an acute respiratory problem with the aim to speed up recovery. These investigators reviewed the evidence behind this use of airway clearance techniques in children without underlying disease.
They stated that few studies have been performed; many different techniques are available and the therapies used are often poorly specified.
It is necessary to name the specific airway clearance technique used in treatment rather than to just state "chest physiotherapy," a term that is often confused with chest clapping or vibration plus postural drainage.
There is little evidence that airway clearance techniques play a role in the management of children with an acute respiratory problem. Physicians routinely prescribing airway clearance techniques in previously healthy children should question their practice.
Paul, MN is an inflatable vest connected to a compressor that provides external high-frequency chest wall oscillation. The vest is connected via tubing to an air pulse delivery system. The patient then uses a foot pedal to apply pressure pulses that cause the vest to inflate and deflate against the thorax creating an oscillatory or vibratory motion.
High-frequency chest compression devices have been shown to increase sputum production in CF patients. The abnormally composition of secretions from affected epithelial surfaces results in increased viscosity. It has been theorized that high-frequency chest compression devices are particularly effective in clearing the abnormal secretions of CF because vibratory shear forces facilitate expectoration by reducing the viscosity of these secretions, much in the same way that shaking jello causes it to become fluid.
However, high-frequency chest compression vests have not been proven to be more effective than manual chest physiotherapy. It can be used in place of manual chest physiotherapy for patients with CF where manual chest physiotherapy is unavailable.
High-frequency chest wall compression devices have been promoted for use in conditions other than CF, including non-CF bronchiectasis. However, there are no adequate published controlled clinical studies of high-frequency chest compression devices for conditions other than CF.
Given the unique pathophysiology of CF resulting in the abnormal composition of CF secretions, evidence of the effectiveness of high-frequency chest wall compression devices in CF can not be extrapolated to other pulmonary conditions.
The Vest was cleared by the Food and Drug Administration FDA for a wide variety of pulmonary conditions based on a k pre-market notification; thus the manufacturer was not required to submit the type of evidence of effectiveness that would be required to support a pre-market approval PMA application.
In addition, there are no adequate studies comparing high-frequency chest compression to other, relatively simple and substantially less expensive devices e. The American College of Chest Physicians' evidence-based clinical practice guidelines on non-pharmacologic airway clearance therapies McCool and Rosen, recommend oscillatory devices e.
The Vest is only available for purchase it can not be rented ; the air pulse delivery system an air-pulse generator and flexible hoses are available for rental or purchase.
There is controversy surrounding the use of high-frequency chest physiotherapy devices for indications other than CF.Dear Twitpic Community - thank you for all the wonderful photos you have taken over the years.
We have now placed Twitpic in an archived state. "Knightfall" is a – Batman story arc published by DC Comics. It consists of a trilogy of storylines that ran from to , consisting of "Knightfall", "Knightquest", and "KnightsEnd".The story takes place over approximately six months.
TORTOISE SHELL. with Brief Reports on Treating Aplastic Anemia and Parkinson’s Disease. by Subhuti Dharmananda, Director, Head Office, Institute for Traditional Medicine, Portland, Oregon.
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