Download - 5 High Frequency Oscillatory Ventilation
- 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
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- PCIRV
-
- Paralysis
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- High FiO 2
- Air Leak Syndrome
- ECMO Candidates
4. Oxygenation Index
- OI =FiO 2x Paw
- PaO 2
- Predictor of mortality
- High value = bad outcome
5.
- MV wont cure cancer
- HFOV wont help with:
- COPD
- IPF
- Asthma
- Sarcoidosis
HFOV Adult Patient Selection 6. HFOV - Why 7. HFOV Objectives
- Support Lung
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- Oxygenation
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- CO 2Removal
- 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. 53% 67% 31%37% 31% 30% 30 day mortality 5.1 5.7 7.2 2.7 4 # of days CV pre HFOV 49 33 28 24 12 29 OI 23 22 27 22 25 APACHE II 17 24 16 75 432 70 n Fort (1997) Mehta (2001) Anderson (2002) MOAT II (2002) ARDS Net (2000) Duke (2005) 12. 13. HFOV - Where?
- ICU
- Transport Limitation
14. HFOV - What? 15. HFOV
- Where is the PEEP, tidal volume, graphics, and respiratory rate on this machine!?.
- Anonymous Surgeon
16. HFOV Design
- Magnet
- Bias Flow
- CPAP with a wiggle
- Expiratory Resistance
- ACTIVE EXHALATION
17. Ventilator Settings
- Hertz = BPM
- Power (Amplitude P)
- Paw
- FiO 2
- Bias Flow
- Inspiratory time %
18. CO 2Removal
- Hertz
- Amplitude ( P)
19. Primary control of CO 2is by the stroke volume produced by the Power Setting 20. CO 2Removal 21. . 22. HFOV Settings: Inspiratory Time %
- 33%= 1:2 I:E Ratio
-
- Default
- 50%= 1:1 I:E Ratio
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- Caution
23. Oxygenation
- Paw
- FiO 2
- What was that Oxygenation Index thing?
24. Oxygenation
- The Paw is used to inflate the lung
- Paw = Lung Volume
- Paw =PaO 2
- (usually)
- Use blender to adjust FiO 2
25. HFOV Controls PaO 2 PaCO 2 26. Bias Flow CDP Control Balloon x 27. Pressure to Lung 28. HFOV Pressure Attenuation 29. 30. Mechanisms of Gas Exchange 31. HFOV - How Initial Settings
- FiO 2=1.0
- Hz= 5.0
- Power setting =5
- Paw =CMV + 5
- Insp Time = 33%
- Flow = 30
32. Clinical Observations
- Chest Wiggle Factor
- CXR T8-9
- Pulse oximetery
- TCO 2
- ABG
33. Weaning
- Wean FiO 2for Sats > 90%
- When FiO 260%, wean Paw by 1
- Return to CMV when:
-
- FiO 2< 40%
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- Paw 15-20
-
- Amplitude < 40
34. HFOV: Conversion
-
- Pressure limited ventilation
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- Delivered tidal volume ~6 ml/kg
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- PEEP ~10 cm H 2 O
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- Adjust for Paw same as HFOV
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- FiO 2~40 - 50%
35. Signs of Failure
- OI > 42 at 48 hrs HFOV
- Unable to wean FiO 2> 10% within 24 hours
- Unable to PaCO 215
- FiO 2> 60%
- PEEP>10
- PIP >35
- Paw>15
- Respiratory acidosis
- Inadequate alveolar ventilation
- Pt. Values:
- OI 21
- FiO 270%
- PEEP12
- PIP 36
- Paw24
- pH7.09
- PaCO 2 200
44. HFOV: Initiation
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- Initial HFOV settings
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- FiO 2 100%
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- Paw 30
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- Amplitude62
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- Hz5.0
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- It% 33%
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- Bias flow30
- Arterial blood gases
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- pH7.26*7.09
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- PaCO 2 114*200
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- PaO 2184*80
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- HCO 352
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- BE22
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- SaO 2 95.2
- *ABG prior to HFOV
45. Management: Strategy
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- HFOV settings
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- FiO 2 80%
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- Paw 30
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- Amplitude62
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- Hz 4.0
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- It% 50%
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- Bias flow30
- Arterial blood gases
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- pH7.35* 7.26
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- PaCO 2 88* 114
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- PaO 2104* 88
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- HCO 349
-
- BE22
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- SaO 2 96
- * ABG prior to changes in parameters
46. Management: 24 hours
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- HFOV settings
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- FiO 2 60%
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- Paw 26
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- Amplitude62
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- Hz 4.0
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- It% 50%
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- Bias flow30
- Arterial blood gases
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- pH7.44
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- PaCO 2 74
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- PaO 297
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- HCO 350
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- BE24
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- SaO 2 95
47. HFOV Day 7
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- HFOV settings
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- FiO 2 50%
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- Paw 16
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- Amplitude50
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- Hz 5.0
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- It% 40%
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- Bias flow40
- Arterial blood gases
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- pH7.41
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- PaCO 2 66
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- PaO 283
-
- HCO 343
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- BE16
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- SaO 2 95
48. 49. Why did HFOV succeed?
- Low pressure swings allowed air leaks to seal
- Paw recruited collapsed lung
50. Derdak AJRCCM 2002 51. HFOV Summary
- CPAP
- Small pressure swings
- Lung protection
- Lung support
- Ultimate low Vt strategy
- Start early
- Be aggressive