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High Frequency Oscillatory Ventilation

High Frequency Oscillatory Ventilation. Who Why When Where What How. ?. Neonatal Uses of HFOV. Hyaline membrane disease Persistent pulmonary hypertension Pulmonary interstitial emphysema (prevention and treatment) Sepsis / Pneumonia Congenital diaphragmatic hernia

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High Frequency Oscillatory Ventilation

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  1. High Frequency Oscillatory Ventilation Who Why When Where What How ?

  2. Neonatal Uses of HFOV • Hyaline membrane disease • Persistent pulmonary hypertension • Pulmonary interstitial emphysema (prevention and treatment) • Sepsis / Pneumonia • Congenital diaphragmatic hernia • Meconium aspiration syndrome

  3. HFOV “Adult” Indications • ARDS • PCIRV • Paralysis • High FiO2 • Air Leak Syndrome • ECMO Candidates

  4. Oxygenation Index OI = FiO2 x Paw PaO2 • Predictor of mortality • High value = bad outcome

  5. MV won’t cure cancer HFOV won’t help with: COPD IPF Asthma Sarcoidosis HFOV Adult Patient Selection

  6. HFOV - Why

  7. HFOV Objectives • Support Lung • Oxygenation • CO2 Removal • Reduce Vent Induced Lung Injury

  8. Carney, CCM 2005

  9. CMV vs HFOV

  10. HFOV- When • Timing is everything • ASAP • 1-5 days of CMV • Not as a last resort

  11. HFOV - Where? • ICU • Transport Limitation

  12. HFOV - What?

  13. HFOV “Where is the PEEP, tidal volume, graphics, and respiratory rate on this machine!?”……. AnonymousSurgeon

  14. HFOV Design • Magnet • Bias Flow • CPAP with a wiggle • Expiratory Resistance • ACTIVE EXHALATION

  15. Ventilator Settings • Hertz = BPM • Power (Amplitude P) • Paw • FiO2 • Bias Flow • Inspiratory time %

  16. CO2 Removal • Hertz • Amplitude ( P)

  17. Primary control of CO2 is by the stroke volume produced by the Power Setting

  18. CO2 Removal

  19. .

  20. HFOV Settings: Inspiratory Time % • 33%= 1:2 I:E Ratio • Default • 50%= 1:1 I:E Ratio • Caution

  21. Oxygenation • Paw • FiO2 • “What was that Oxygenation Index thing?”

  22. Oxygenation • The Paw is used to inflate the lung • Paw = Lung Volume •  Paw =  PaO2 (usually) • Use blender to adjust FiO2

  23. HFOV Controls PaO2 PaCO2

  24. x Bias Flow CDP Control Balloon

  25. Pressure to Lung

  26. HFOV Pressure Attenuation

  27. Mechanisms of Gas Exchange

  28. HFOV - HowInitial Settings • FiO2 = 1.0 • Hz = 5.0 • Power setting = 5 • Paw = CMV + 5 • Insp Time = 33% • Flow = 30

  29. Clinical Observations • Chest Wiggle Factor • CXR T8-9 • Pulse oximetery • TCO2 • ABG

  30. Weaning • Wean FiO2 for Sat’s > 90% • When FiO2 60%, wean Paw by 1 • Return to CMV when: • FiO2 < 40% • Paw 15-20 • Amplitude < 40

  31. HFOV: Conversion • Pressure limited ventilation • Delivered tidal volume ~6 ml/kg • PEEP ~10 cm H2O • Adjust for Pawsame as HFOV • FiO2 ~40 - 50%

  32. Signs of Failure • OI > 42 at 48 hrs HFOV • Unable to wean FiO2 > 10% within 24 hours • Unable to PaCO2 <100 with pH 7.25

  33. “On Patient” Issues • Inability to increase Paw • Fluctuating Paw • Changes in settings • Inappropriate patient response

  34. Inappropriate Patient Response • Need for ETT suctioning • Low lung volume • Overdistended lung • Marginal cardiovascular status

  35. Tricks • Prone positioning • ETT Leak • Bronchoscopy

  36. HFOVCase Study Putting it all together

  37. Pressure limited A/C FiO2 70% Vt 296 VE 9.2 RR 32 PEEP 12 Paw 24 PIP 36 I:E 1:1 Arterial blood gases pH 7.09 PaCO2 200 HCO3 49 PaO2 80 BE 26 SaO2 91 A-a gradient 169.1 OI 21 Day 16 CMV

  38. “Oh yeah, did I mention…?” • 23 y/o female • ARDS • 3 CT • Prone • iNO • ECMO candidate

  39. Indication: OI > 15 FiO2 > 60% PEEP > 10 PIP > 35 Paw > 15 Respiratory acidosis Inadequate alveolar ventilation Pt. Values: OI 21 FiO2 70% PEEP 12 PIP 36 Paw 24 pH 7.09 PaCO2 200 HFOV: Indications

  40. Initial HFOV settings FiO2 100% Paw 30 Amplitude 62 Hz 5.0 It% 33% Bias flow 30 Arterial blood gases pH 7.26 *7.09 PaCO2 114 *200 PaO2 184 *80 HCO3 52 BE 22 SaO2 95.2 *ABG prior to HFOV HFOV: Initiation

  41. HFOV settings FiO280% Paw 30 Amplitude 62 Hz 4.0 It% 50% Bias flow 30 Arterial blood gases pH 7.35 * 7.26 PaCO288 * 114 PaO2 104 * 88 HCO3 49 BE 22 SaO2 96 * ABG prior to changes in parameters Management: Strategy

  42. HFOV settings FiO2 60% Paw 26 Amplitude 62 Hz 4.0 It% 50% Bias flow 30 Arterial blood gases pH 7.44 PaCO2 74 PaO2 97 HCO3 50 BE 24 SaO2 95 Management: 24 hours

  43. HFOV settings FiO2 50% Paw 16 Amplitude 50 Hz 5.0 It% 40% Bias flow 40 Arterial blood gases pH 7.41 PaCO2 66 PaO2 83 HCO3 43 BE 16 SaO2 95 HFOV Day 7

  44. Why did HFOV succeed? • Low pressure swings allowed air leaks to seal • Paw recruited collapsed lung

  45. Derdak AJRCCM 2002

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