INTERNATIONAL VENTILATOR USERS NETWORK
an affiliate of Post-Polio Health International
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VOLUME 31, NUMBER 6
Audrey J. King, MA
This year's Margaret Pfrommer Memorial Lecture in Long-Term Mechanical Ventilation was awarded to Audrey J. King and was presented on October 30th at CHEST 2017 in Toronto, Canada. This was the 17th year the lecture was given at the annual meeting of pulmonologists to educate physicians about home mechanical ventilation. Established in 1999 by Dr. Allen Goldberg and Dr. Eveline Faure, the lecture honors polio survivor and advocate Margaret Pfrommer from Chicago, Illinois. Pfrommer, a quadriplegic from polio, spent part of her life in a nursing home after her mother’s death. This experience compelled her to become an advocate for herself and for all those with significant disabilities. The purpose of the endowment is to honor an individual who possesses superior knowledge of home mechanical ventilation (HMV) and who promotes the health professional/patient partnership.........MORE
Diane Coleman, JD
Victoria recently became first Australian state to legalize assisted dying, which will go into effect in 2019. While most people’s eligibility is based on a six-month prognosis, the bill includes a “special” provision extending that “to 12 months for people with neurodegenerative diseases such as Motor Neurone Disease.” The legislation marks the first time in the world that a parliament has gone through an extensive process to introduce voluntary assisted dying. Other countries have introduced laws through referendum or a court process............MORE
Vol. 31, No. 6, December 2017
Editor: Brian Tiburzi
Designer: Brian Tiburzi
Permission to reprint must be obtained from Post-Polio Health International (PHI) at email@example.com.
Ventilator users, health professionals, non-profits, company representatives – send comments and updates to firstname.lastname@example.org.
When Air Becomes Breath: The 2017 Margaret Pfrommer Endowed Memorial Lecture in Home Mechanical Ventilation
Audrey J. King, MA, Toronto, Canada
Audrey J. King
This year's Margaret Pfrommer Memorial Lecture in Long-Term Mechanical Ventilation was awarded to Audrey J. King and was presented on October 30th at CHEST 2017 in Toronto, Canada. This was the 17th year the lecture was given at the annual meeting of pulmonologists to educate physicians about home mechanical ventilation. Established in 1999 by Dr. Allen Goldberg and Dr. Eveline Faure, the lecture honors polio survivor and advocate Margaret Pfrommer from Chicago, Illinois. Pfrommer, a quadriplegic from polio, spent part of her life in a nursing home after her mother’s death. This experience compelled her to become an advocate for herself and for all those with significant disabilities. The purpose of the endowment is to honor an individual who possesses superior knowledge of home mechanical ventilation (HMV) and who promotes the health professional/patient partnership.
When Air Becomes Breath - Part I
As a ventilator user since childhood and a retired psychologist I’m extremely honoured to receive this Award. In many ways, this is also a tribute to your specialty, because I am still here nearly seven decades later.
I got polio at age 9, during the last of the epidemic years. I spent two months in an iron lung, two years in hospital, seeing my parents for two hours only on the weekends and finally coming home at age 11.
At age 15, I returned to school - the local high school. There were no power wheelchairs yet. Other kids pushed me home to school, class to class, and helped with books and coats. The school office staff helped with the washroom. The school community took me on, you might say.
By age 16, I slid into respiratory failure and found myself in the dreaded iron lung again. The cuirass (a more portable negative pressure ventilator) enabled me to come home again - much more quickly this time. I have used non-invasive ventilation (NIV) ever since, except for two episodes I'll write about below.
I was accepted at University (but only conditionally, I found out later). “What was the point? She’ll never get a job,” those with authority said. Thank goodness I never knew.
After graduation I was employed as a psychologist at a major children’s Rehabilitation Centre. Responsibilities included, among other things, assessment, planning, and counselling for children with spina bifida, cerebral palsy, traumatic brain injuries and so on.
After 30 years of full-time employment, I retired to care for and coordinate the care of my aging mother with dementia who lived with me. This wasn't easy - but the shock value of seeing someone such as myself being her advocate and caregiver did have some advantages!
Over the years I’ve learned a lot - both personally and professionally. I‘ve survived major health issues, as well as some amazingly improbable lifestyle adventures. I’ve benefited enormously through the evolution of technology - power wheelchairs, negative to positive pressure ventilators, non-invasive to invasive ventilation and back to NIV again.
I’ve learned even more from the families and children who I've been privileged to work with. Resilience, in the face of many challenges, the insatiable drive to become who you’re meant to be and what really matters, are just some of the lessons learned.
I hope to share with you these insights as I focus on what makes life valuable, rather than on the acutely ill ventilated patient or pulmonary pathologies which you know so well. I will share the perspectives of long-term ventilator-dependent folk whose strongest sense of “self-identity” is their role and value in life, not their dependence on mechanical assistance for breath.
This inherent drive “to be who you’re meant to be” plays out in different ways depending on where you are at in life’s journey….and can sometimes override attention to necessary health issues. For example:
I’m thinking here of an embarrassed teenager discharged from hospital with a cuirass (right) following near fatal hypercapnia. Hated it with a passion, feared the neighbours would find out, teenage friends would know. Refused to use it, resulting in hospital readmission and compliance. But, the patient never really believed it was needed. Several years later, on a family vacation, the vent motor failed. By the time the family came home several days later, the truth was irrefutable. During teenage years, self-identity and body image is HUGE.
I’m thinking here of a 28-year-old mother with SMA, happily married and pregnant with her first child. It was a precarious pregnancy due to respiratory insufficiency and failure. The drive of a young woman to become a mother can surpass awareness or concern about personal physical concerns.
And then there is the highly-respected professor with SMA invited to give a prestigious keynote speech in a major Canadian city some 3,000 miles away. Unbeknownst to those who invited her, she now has a G-tube and is unable to drive her wheelchair. She is able to speak only a few sentences before drawing another breath with her increasingly-needed mouth ventilation support.
The insatiable drive of a mid-career person to deliver resulted in a pre-recorded video speech followed by a live Skype session for Q&A. Her keynote address was smooth, thought-provoking and of the quality expected. What the audience did not know was that thanks to technology and personal ingenuity, the speech had been prepared and pre-recorded in over 20 different segments that were seamlessly stitched together. What the audience also didn't know (and why should they?) was that this was possible because of her trust and relationship with her excellent pulmonary team.
And then, of course, what can we say about the normal sex drive of a young man. It’s hard to deny that part of life when you are young, intrinsically, hormonally driven, but severely disabled and ventilator dependent.
The job of the patient is to “get on with life.” The job of the physician or health care team is to prescribe and monitor ventilators and lung health. Different roles! Conflicts and misunderstandings can occur, resulting in lost opportunities for discussion, explanation, fear reduction and optimal treatment.
The patient's understanding of what is of “greatest” importance may be quite different from that of the physician, as you can see in this diagram:
The goal is to bridge these two “realities” so as to more effectively achieve a relationship where optimal pulmonary support enables a ventilator user to get on with his/her own life.
How can we do this, you might ask?
I see it as an interactive journey that is as variable as individuals are. It progresses through four stages, weaving in and out of these stages during episodes of illness, new equipment and so on.
In the beginning, patients and families new to long-term ventilation are totally dependent on the skilled expertise of clinicians. With time, health stability and confidence, the ventilator user (or parents if the patient is a child) moves into an “apprenticeship” stage. Here they need to learn what it’s all about, how everything works, when to seek help, how to order supplies and so on.
With time, knowledge and experience, their confidence grows. This enables patients to move into a partnership mode, where decisions are made by the ventilator user and his/her physician through informed collaboration, discussion, questioning, debating, even arguing…maybe even repeatedly.
The expertise phase is reached when years of living with HMV has equipped the vent user with enough knowledge and experience to question and/or seek equipment options, convince medical folk to listen, to believe, to discuss and to respect the knowledge of the patient with respect to their own body and its unique needs – as well as the importance of what he or she needs to do.
THAT is not always easy!
For example, I’d just returned from a speaking tour in Japan, having decided (with the generous help of an RT friend) that positive pressure on a much more transportable LTV900 ventilator was much more comfortable when sleeping than my bigger, bulkier volume ventilator, the PLV100. After the trip, I arrived for a previously scheduled sleep study, both ventilators in hand. I wanted to know if both were equally effective and, if so, might I be able to switch. The sleep technologist was startled, but it was late at night, so she acquiesced and studied me on both.
A more potentially life-threatening example occurred 20 years ago when a serious bout with pneumonia, followed by a complicated cholecystectomy, necessitated invasive ventilation. After 18 months or so, I wanted the tracheotomy closed. I was now back home and living with the challenging restrictive home care consequences of “being on a ventilator.”
On my own initiative, I began corking the trach and sleeping with my nasal mask again. It seemed to me that NIV was just as effective, but I needed encouragement and reassurance from the experts. “Why?” I was asked. “You’ll only need it again.” It was unnerving to get no support, but I stuck to my guns and was persistent in reaching my trach-free goal.
That was 18 years ago.
As a child and young adult, I honestly believed doctors were GODS - all powerful, to be honoured and respected, never contradicted or questioned. I evolved from child to teen to young adult feeling confident and secure in this knowledge. My body, my breathing were the business of doctors, not mine. I had other things to do.
As a teen, I began to question if I even really needed the cuirass at night. (Yes, I was that troubled teen who went camping.) As a young adult, I came to Toronto – often considered the mecca of medical expertise – and decided to ask the question.
The answer was shocking. Having developed serious scoliosis, not only did I indisputably need it, spinal stabilization was required – or I would be dead in 3 years. “You probably wouldn't survive the surgery,” I was told, “but if you do, you’ll have a tracheostomy you’ll never get rid of because you won’t be able to breathe on your own again. Furthermore, even if you do surmount these likelihoods, your life span is about 10 years - at the most.”
That was 50 years ago. So, as you can see, I’m way past my predicted “best before” date!
What was my choice? I opted for the surgery. I awoke in a panic, couldn’t speak, pulled out the endotracheal tube. Alarm bells went off everywhere. Nobody had told me what to expect, what intubation was.
Somehow I managed to convince that blond-headed intensivist not to put it back. Have you ever tried to plead convincingly after a traumatic extubation, after 10 hours of surgery? NOT EASY! (I can still see his blond hair and name tag – Dr. D. Andrews.)
Many hours later, I awoke to neck muscles stiff as a board, exhausted from the effort of breathing. I pleaded for the cuirass, convincing the doctors how mean it was to wean me off this way. “You don’t need it! You’re doing fine,” I was told. Convincing the doctors how mean it was to do surgery then make me go cold turkey took great effort – again. The cuirass did come back for a few weeks. Then it was gone!
“Psychologically dependent,” the orthopedic surgeon said. “You never really needed it at all.” Embarrassed by being so psychologically weak, I was nevertheless thrilled to be rid of it and looking forward to a freer life once I got up and about again. (Needless to say, respiratory folk were not consulted.)
Five years later, I was in life-threatening respiratory failure. As I recall my PaCO2 levels were in the 70s and my PaO2 in the 50s. That same pulmonologist who'd told me I wouldn’t survive surgery five years earlier, lectured me severely. “What the hell were you thinking? Whatever made you think you didn’t need it?”
Blame the victim, as they say.
It was then I realized if I wanted to survive, I needed to move beyond “dependence.” I needed to ask questions, learn everything I could about breathing, lung function and my own particular needs. Become an apprentice. I needed knowledge so I could evolve into a collaborative partnership relationship with the medical specialists in my life.
Of course, the cuirass returned as my nocturnal bed partner again. But, it didn't fit anymore, and there was no easy way to get one custom made.
I sought many an orthotist and even mail-ordered one from the USA… that didn’t fit either. I felt like the very last polio “responaut” in the world, yet common sense told me otherwise. There had to be expertise somewhere! And, I had to survive!
My search led me to GINI's 1981 international conference in Chicago, “Whatever Happened to the Polio Patient?”
I went. I saw. I learned. Everyone concerned about HMV issues was there from all around the world – physicians, vent users, families, therapists, advocates.
And that experience brought me to yet another realization. The incredible power of all the players in the HMV arena convening together on an equal, non-hierarchical basis was profound. Learning, sharing, debating together...over meals, in hotel rooms…sometimes long into the night! It was a partnership event in the truest sense.
Audrey King (center) at the GINI's 1981 conference, Whatever Happened to the Polio Patient?, with Dr. Augusta Alba (left).
Many significant events grew out of that gathering, including IVUN – an impressive networking, archival and information resource for all things HMV.
And Margaret Pfrommer was there, along with some of Dr. Allen Goldberg’s littlest patients.
Some of us came back to form CILB (Citizens in Living and Breathing). We were an after-hours grassroots charitable organization – a small mix of parents, vent users, an OT, an RT, a social worker and many other advocates. During our seven-year existence, we held several major educational conferences with key pulmonologists who shared this partnership orientation. We provided peer support to other vent users, especially those who were new to the game. We impacted significant government changes in providing community living opportunities for HMV patients (e.g. supportive housing) and achieved legal exemption for routine suctioning within Ontario’s Regulated Health Professionals Act.
Essential knowledge also comes from the risks and chances a ventilator user takes as he or she journey through life.
With my career assured, vent needs sorted out, and dollars in the bank, I was driven to travel – planning carefully – or so I thought.
The first trip was to Barbados. I soon discovered that cycle matters. The ventilator started and stopped all night. It seemed I was doomed to turn around and come right back home until my dad’s army buddy came to the rescue. In his retirement there, he ran an illicit rum-making operation which was powered by a generator. He generously “went dry” for the week so I could use it. Electricity, I discovered, is more that watts and volts!
My second trip was to England, canal boating on the Grand Union Canal on an accessible canal boat. I’d taken all the necessary converters, transformers and adaptors and, as a back-up precaution, had arranged to borrow a UK unit from St. Thomas’s hospital in London. My friend in England had rented a generator which was on the back of the boat (it always rains in England) with cable running alongside the boat and in through the window where I slept. The white box pictured on the right is the Monaghan ventilator inside the narrowboat, and I am sleeping on a narrow shelf above it.
I arrived at Gatwick safely, but not the ventilator. It was winging its way to Switzerland.
As negative pressure ventilation switched to positive, the units became smaller and smaller and much more easily transportable - in the cabin - WITH ME!
From then on, I insisted my ventilator stay with me in the cabin of the airplane. Fortunately, this was becoming increasingly possible due to the evolution of smaller and smaller technology.
With more well-planned and successful trips behind me, I signed up for a week’s adventure on a 100-year-old three-masted schooner that sailed out of Amsterdam to the North Sea and “fell dry” (that means resting on the bottom of the sea with no land anywhere in sight). Again I planned very carefully with lots of letters seeking reassurance regarding electricity supply. I arrived on board only to discover there was no electricity at night because it was being generated for use the next day. There was half-an-hour or so of panic until the crew figured out how to power the necessary ventilator via a cable woven from the generator through the ships corridor’s to my sleeping area. Another close call averted! So, that’s my story in a nutshell.
Part 2 of this lecture will appear in the February 2018 issue of Ventilator-Assisted Living (Vol. 32, No. 1).
Past Awardees of the Margaret Pfrommer Memorial Lecture in Long-Term Mechanical Ventilation
Dominique Robert, MD
Colin Sullivan, BScMed, MB, BS, PhD, FRA PhD, FRACP, FAA
Augusta Alba, MD
Joseph Ramsdell, MD, FCCP
Anita Simonds, MD, FRCP
John Downes, MD, FCCP
Barry Make, MD, FCCP
Allen Goldberg, MD, FCCP
Dudley Childress, MD
Joshua Benditt, MD, FCCP
Nicholas Hill, MD, FCCP
Norma Braun, MD, FCCP
Roger Goldstein, MD, FCCP
Judith Fischer, MSLS, and Joan L. Headley, MS
John R. Bach, MD, FCCP
Thomas G. Keens, MD
VENTILATOR USERS SPEAK
Not Dead Yet President Diane Coleman's Letter to Members of the Victoria (Australia) Legislative Council Opposing Assisted Dying
Victoria recently became first Australian state to legalize assisted dying, which will go into effect in 2019. While most people’s eligibility is based on a six-month prognosis, the bill includes a “special” provision extending that “to 12 months for people with neurodegenerative diseases such as Motor Neurone Disease.” The legislation marks the first time in the world that a parliament has gone through an extensive process to introduce voluntary assisted dying. Other countries have introduced laws through referendum or a court process.
Diane Coleman, President of Not Dead Yet, submitted a letter to the members of Parliament in Victoria while the legislation was under debate:
Neuromuscular conditions and the definition of “terminal”
“I am writing behalf of Not Dead Yet, a national disability rights group in the U.S. that opposes legalization of assisted suicide. We understand that a proposal in Victoria would pertain specifically to neuromuscular disabilities. This letter will focus on misdiagnosis and the uncertainty of terminal predictions by doctors, as well as the significance of breathing support for those of us with these conditions. My own experience illustrates the issues.
“At the age of six I was misdiagnosed as having muscular dystrophy and my parents were told that I would die by the age of 12. A few years later I was re-diagnosed with spinal muscular atrophy, a progressive neuromuscular condition which has a longer lifespan. Since age eleven, I have used a motorized wheelchair. Beginning 17 years ago I have used breathing support at night. The type of support I need is called a BiPAP. Over the years, the pressures required to sustain my breathing increased.
“I am now age 64. Four years ago, the doctors determined that I do not have spinal muscular atrophy, and I am now diagnosed with another neuromuscular label, congenital myopathy. About two and a half years ago, I went into respiratory failure. Since then I have used breathing support most of the day as well as at night. If I did not use this support, I would likely have respiratory failure within a few days at most. Under most definitions, I qualify as 'terminal,' even though I have already lived two and a half years this way.
“Throughout my adult life, I have worked full time, first as an attorney and then directing nonprofit disability related organizations. Over the last two years, I have continued to run Not Dead Yet, which has four staff and numerous volunteers across the country. I have spoken at conferences, published articles, been interviewed by at least 20 press outlets, submitted testimony in legislatures, and provided the day-to-day management an organization requires.
“As a severely disabled person who depends on life-sustaining treatment, I would qualify for assisted suicide at any time if I lived where assisted suicide is legal. If I became despondent, for example if I lost my husband or my job, and decided that I wanted to die, I would not be treated the same as a nondisabled and healthy person who despaired over divorce or job loss. Where assisted suicide is legal, I would be treated completely differently due to my condition.
“This is just one example of how slippery the definition of terminal really is. Under assisted suicide policies, many people with disabilities would qualify for assisted suicide and be denied the suicide prevention and other supports that nondisabled people could take for granted if they expressed a desire to die. Assisted suicide laws are inherently discriminatory against old, ill and disabled people.
“We urge you to vote no on the assisted suicide bill. The dangers of mistakes and abuse are simply too high, not only for people like me, but for everyone.”
EQUIPMENT & SUPPLIES AVAILABLE
Looking for ventilator equipment and supplies?
IVUN is contacted from time to time by individuals looking to donate either used equipment or new supplies that are no longer needed. Below are items available from two such individuals. They may be willing to ship these items if you live outside those areas. If you are interested, please contact us at email@example.com. Please write "donated equipment" in the subject line and specify which items you are interested in. IVUN will then connect you with the donor, with whom you can make arrangements to take possession of the items. IVUN has not inspected this equipment. It is available as is.
Emerson Cough Assist CA3000
Kimberly-Clark Closed Suction System
UltraFlex Male External Catheter
Covidien Shiley Inner Cannula (Disposable)
Kimberly-Clark Closed Suction System
Halyard Turbo-Cleaning Closed Suction System
Covidien Curity Drain Sponges
Covidien Curity Gauze Sponges
Medline Tracheostomy Clean & Care Kit (with HP & Saline)
CathSecure Plus Water Resistant Multi-Purpose Tube Holder
Bard Dispoz-A-Bag Disposable Urinary Leg Bag
Bard Latex-Free Dispoz-A-Bag Urinary Leg Bag
CareFusionAirLife Nonconductive Respiratory Therapy Filter, Bacterial/Viral Rententive
CareFusion Patient Circuit W/O PEEP, 22 mm, SPU
Covidien Monoject 12 mL Syringe
BD Leur-Lok Tip 10 mL Syringe
Cavilon No Sting Barrier Film
Loris Antiseptic Sterile Solution & Swab
Coloplast Protective Skin Barrier Wipes
Sodium Chloride Inhalation Solution, USP 0.9%
Covidien Shiley Tracheostomy Tube Cuffed with Disposable Inner Cannula
Click below for more details.
Orphan Drug Tax Credit
The final version of the Tax Cuts and Jobs Act being passed this week by Congress includes a cut of the Orphan Drug Tax Credit from 50 percent of qualified clinical testing expenses to 25 percent. While this is not what many in the disability community were aiming for, it avoids a full elimination of the ODTC that the House's original bill had called for.
Earlier this month, IVUN joined over 160 patient organizations in sending a letter, drafted by the National Organization for Rare Disorders (NORD), to the tax reform conference committee in support of strengthening the ODTC provision, or at the very least, keeping the Senate's proposed 27.5 percent rate intact. The letter and the list of organizations that signed on can be read here.
Education Department Seeks Delay of IDEA Rule
The Trump administration wants to delay implementation of an Obama-era regulation designed to ensure that kids from certain backgrounds aren’t unnecessarily placed in special education. In a Federal Register notice, the U.S. Department of Education is seeking comment on a plan to delay enforcement of what’s known as the “significant disproportionality” rule for two years.
“We know there is a problem that needs to be fixed — delaying implementation will only hurt children who are already in school and send a message to them that they are not (as) important as other children are,” said Curt Decker, executive director of the National Disability Rights Network.
RECENT RELEVANT PUBLICATIONS
Noninvasive Respiratory Management of Patients With Neuromuscular Disease
John R. Bach, MD
“Quality of life is optimized by noninvasive management and expense greatly reduced. Unfortunately, the conventional paradigm is that anyone who requires around-the-clock respiratory support needs a tracheostomy tube. Thus, a paradigm shift that is greatly disincentivized by the greater compensation for invasive procedures and management in general, is unlikely in the currently unsustainable American health care system. Noninvasive respiratory management is only desirable for patients and taxpayers, neither of whom have lobbyists for their interests.” Full article.
Annals of Rehabilitation Medicine, 2017 August, 41(4):519-38.
Trends in mechanical ventilation: are we ventilating our patients in the best possible way?
Raffaele L. Dellaca’, Chiara Veneroni, and Ramon Farre’
“Since their initial appearance, mechanical ventilators have become more sophisticated and expanded their application from the intensive care unit (ICU) to the respiratory medicine ward and even to patients’ homes for long-term treatments. This was the result of combining the advances in our understanding of respiratory physiology, pathophysiology and clinical management of patients together with technological progress in mechanical, electronic and biomedical engineering.” Full article.
Breathe, 2017 13: 84-98.
Successful Extubation After Weaning Failure by Noninvasive Ventilation in Patients With Neuromuscular Disease: Case Series
Sun Mi Kim, MD, et al.
“NIV may promote successful weaning in neuromuscular patients with experience of reintubation.” Full article.
Annals of Rehabilitation Medicine, 2017 June, 41(3):450-455.
Aging effects on airflow dynamics and lung function in human bronchioles
JongWon Kim, Rebecca L. Heise, Angela M. Reynolds, Ramana M. Pidaparti
“In general, our dynamic lung function and respiratory mechanics degrade as we grow older,” said Ramana Pidaparti, a professor and associate dean for academic programs in UGA's College of Engineering, who served as the study's senior author. “Our study demonstrates and quantifies the effects of aging on airflow dynamics and lung capacity. Understanding these underlying mechanisms can help us develop ways to better treat elderly patients.” Full article.
PLOS One, Aug 28, 2017.
JIVD/ERCA Conference in 2018
March 15 - 17, 2018, 3rd International Joint Meeting of the JIVD (Journes Internationales de Ventilation Domicile) and ERCA (European Respiratory Care Association), Cité Centre de Congrès, Lyon, France. See Preliminary Program. www.jivd-aer.com
Canadian Respiratory Conference 2018
FOCUS Spring 2018
American Thoracic Society 2018
May 18-23, 2018, American Thoracic Society's 2018 International Conference, San Diego, California.
CCHS Family Conference 2018, alongside The 5th International CCHS Conference
June 20-23, 2018 at The Chase Park Plaza, St. Louis, Missouri, USA. Registration is now open.
FOCUS Fall 2018
September 14-15, 2018, Fall FOCUS, Hotel Irvine, Irvine, California. More details.
ERS International Congress 2018: Paris
September 15-19, 2018, Paris expo Porte de Versailles. The abstract submission deadline is Februrary 15th. Find up-to-date information here.
Ventec Recognized with the 2017 North American Frost & Sullivan Award for New Product Innovation
Frost & Sullivan recognized Ventec Life Systems with the 2017 North American Frost & Sullivan Award for New Product Innovation for its portable unified respiratory system, VOCSN. Ventec Life Systems received FDA clearance for the VOCSN in April 2017. The innovative product combines a critical care ventilator, 6 L/min equivalent oxygen concentrator, Touch Button Cough™ assist, hospital grade suction, and high-performance nebulizer in a single device, enabling improved quality of care and substantial cost savings for patients, payers, and caregivers. The unified device not only lowers the cost of acquisition, storage, maintenance, and training, but also consumes less power than systems that require multiple devices.