1 3100B Clinical Training Program 3100B HFOV VIASYS Healthcare
2 HFOV at Alveolar Level Nieman,, G, SUNY 1999
3 Who DO We Treat? Only Pathology studied to date has been ARDS Questions about management of adults with massive airleak and BP fistula? Questions about management of Respiratory Failure based on any other disease process
4 HFOV: One More Tool in the Management of ARDS How does it work? Reduces the risk of further lung destruction. Keeps lung open alveoli at constant pressure. Ventilates very rapidly at very small volumes. Early intervention is key to success.
5 Theory of Operation and Controls
6 3100 A 3100 B Limit Adjust Button No Limit Adjust Button Piston centering adjustable Piston centering connected to I/E Ratio
7 Decoupling of Ventilation and Oxygenation Controls for Oxygenation Paw FiO2 Alveolar recruitment maneuver Controls for Ventilation- takes time! Amplitude Hertz % I time Cuff Deflation Permissive Hypercapnea
8 Oxygenation Oxygenation is primarily controlled by the Mean Airway Pressure (Paw) and the FiO2. Mean Airway Pressure is a constant pressure used to inflate the lung and hold the alveoli open. Since the Paw is constant, it reduces the injury that results from cycling the lung open for each breath
9 Oxygenation Strategies Initial Paw 5 cms> > CMV Paw Paw until you are able to FiO2 to 60% with a SaO2 of 90% or > Avoid hyperinflation - CXR Optimize preload, myocardial function Mean Arterial Pressure > than 75 mmhg
10 Ventilation Controlled by the movement of the pump/piston mechanism Alveolar ventilation during CMV is defined as: f x Vt Alveolar ventilation during HFV is defined as f x Vt 2 Therefore changes in volume delivery ( as a function of Delta-P, Frequency or % Insp. Time) have the most significant affect on ventilation.
11 Regulation of stroke volume The stroke volume will increase if - The amplitude increases ( higher delta P) - The frequency decreases ( longer cycle time) - There is an increase in Inspiratory Time % (time in forward motion) Stroke volume
12 Amplitude is a measurement created by the force that the piston moves which is based on the POWER setting, resulting in a volume displacement and a visual CHEST WIGGLE. It is represented by a peakto-trough pressure swing across the mean airway pressure.
13 Secondary control of PaCO 2 is the Frequency set.
14 The % Inspiratory Time also controls the time for movement of the piston, and therefore can assist with CO 2 elimination. Increasing % Inspiratory Time will also affect lung recruitment by increasing delivered Paw.
15 Clinical Tips With cuffed ET tubes, minimally deflating the cuff may allow airway wall CO 2 to exit the circuit at the tip of the tube
16 Key to Success for ANY Patient considered for HFV Choosing the RIGHT patient. HFV is NOT for every patient. When to Start? Early application provides protection and reduces incidence of further lung damage Rescue may or may not improve mortality chances. The later HFV is started the less chance of survival Gathering the right information before you start in order to make e an informed and appropriate decision. Monitoring the patient is MANDATORY Assessment skills are necessary by everyone at the bedside. Rule #1 Patient tells ALL!
17 When Do We Think about HFOV for the ARDS Patient? When to consider HFOV use? As with all candidates, the earlier the better FiO 2 >60, PEEP>10 with P/F ratio<200 > than 30 Plateau Pressure OI > than 24 OI = (FiO2 x 100) x MAP / PaO2 ARDS Net Protocol Failing Refer to outcome assessment form
18 Initial Settings and Suggestions for Larger Patient Use On 3100 B Patients with ARDS >35 Kg Set Paw 5 cmh20 above CV Paw FiO2 100% Set Hertz at 5-65 Power 4.0, adjust for good chest wiggle I time % at 33% Set Bias Flow at >25 lpm,, may need to go higher
19 Ventilator Strategies-Goals Normalize lung volume Minimize pressure change at alveolar level Wean FiO 2 to a safe level first - Physiological targets include: - Oxygen saturation > 88% < 93% - Delay weaning Paw until FiO2 < ph > PaCO2 in the range of mmhg
20 Ventilation Strategies CWF- adjust Amplitude to target PaCO2 to between Remember it is not uncommon to see an increase in PaCO2 when first transitioned frequency by 1Hz increments if unable to improve ventilation or if Power Setting is maximized Allow permissive hypercarbia if indicated, keeping ph>7.25. If necessary, consider buffering ph for the transition phase.
21 HFOV: Adjusting the settings Hypercapnia delta P frequency I time (deflate cuff)
22 HFOV: Adjusting the settings Hypocapnia frequency delta P
23 HFOV Management Weaning - Wean FiO2 for arterial saturation > 90% Once FiO2 is 60% or less, re-check chest x-ray and if appropriate inflation, begin decreasing the Paw in 2-3 cmh2o increments Wean Delta-P in 5 cmh2o increments for PaCO2 Once the optimal frequency is found, leave it alone
24 Clinical Tips Failure Criteria Inability to decrease FiO2 by 10% within the first 24 hrs. Inability to improve ventilation or maintain ventilation (after optimizing both frequency and amplitude) with PaCO2 < 80 with ph > A transcutaneous CO2 monitor or ABG s are imperative for monitoring CO2 in larger patients.
25 Transition to conventional ventilation Mean airway pressure stable Tolerating position and nursing care No substantial physiologic changes Stable blood gases Resolution of original lung pathology Switch to PCV (TV 6 ml/kg, 1:1 with PEEP 10)
26 Monitoring and Assessment SPO2 CXR ABG- ½ follow Spo2 HR and B.P. TCCo2 very effective Auscultation Wiggle Settings measured Compliance changes This darn thing will enhance my assessment skills!
27 Clinical Assessment Chest Wiggle factor (CWF) must be evaluated upon initiation and followed closely after that. CWF absent or becomes diminished is a clinical sign that the airway or ET tube is obstructed. CWF present on one side only is an indication that the ET tube has slipped down a primary bronchus or a pneumothorax has occurred. Check the position of the ET tube or obtain a CXR. Reassess CWF following any position change.
28 Clinical Assessment Chest X-raysX Obtain the first x-ray x at 1 hour preferably, but no greater than 4 hour mark to determine the lung volume at that time. Paw may need to be re- adjusted accordingly. Always obtain a CXR, if unsure as to whether the patient is hyper-inflated or has de-recruited the lung.
29 Clinical Assessment Chest X-raysX Stopping the piston, or re-positioning the head to shoot an appropriate film is not necessary. Do not remove the patient from HFOV and manually ventilate to shoot the film. The purpose of the x-ray x is to verify the lung volume that the HFOV is producing. A physician, nurse, or therapist should be at bedside to assure the patency of the airway and the patient s s position.
30 When Good Compliance Turns Bad Monitor B.P. and HR Wean Paws on low FiO2 Signs of hyperinflation or increased alveolar dead space Obtain frequent CXRs- 1 hour and Q6 Pay close attention to CWF and Transcutaneous CO2
31 Clinical Assessment Auscultation Heart Sounds - stop the piston, (the patient is now on CPAP); listen to the heart sounds quickly, and start the piston back up. Removing the patient from the ventilator may result in loss of lung volume.
32 Clinical Assessment Auscultation Breath sounds - identifying the normal breath sounds is difficult, since HFOV is not ventilation with a bulk flow of gas through the airway. Listen to the intensity or sound that the piston makes, it should be equal throughout. If not the same sound, re-assess the patient to determine if a chest x-ray x is necessary at this time.
33 Patient Care Suctioning Indicated by decreased or absence CWF, decrease in O2 saturation, or an increase in TcCO2. Remember that each time the patient is disconnected from HFOV, they will potentially derecruit lung volume. Closed suction catheters may mitigate de-recruitment, and you may have to adjust the delta P to compensate for the attenuation of the delta P due to the right angle adapter It may be necessary to temporarily Paw
34 Patient Care Bronchodilator Therapy - Patients who are actively wheezing or have RAD administration via bagging- try to coordinate with suctioning IV terbutaline for patients who do not tolerate disconnects
35 Patient Care Humidification of bias flow accomplished with a traditional heated humidifier Longer, flexible circuit allows patient positioning to prevent skin breakdown
36 Patient Care Sedation or Paralysis Patients may require paralysis for initial transition and then may be sedated to be maintained on the 3100B. Limitation of flow on the 3100B to meet inspiratory demand of an ARDS patient is the reason.
37 Patient Care: Positioning Every position possible including PRONING At least 1 therapist and 1 nurse (risk of disconnection) After change of position, observation of chest wiggle, SpO2 and tcpco2 Re-adjustment of ventilator parameters if needed Check ET tube position
38 Potential Complications Hypotension - may occur Administer serial boluses of fluid until CVP or PCWP has increased by 5-10 mmhg Vasopressors - may be necessary if hypotension persists following fluid boluses
39 Potential Complications Pneumothorax may occur during HFOV Patient may exhibit with progressive hypotension and desaturation CWF may be affected on the pneumothorax side, visual decrease Auscultation may be affected on the pneumothorax side. Distant and dampened sound of piston in comparison to opposite side
40 Potential Complications Endotracheal Tube Obstruction An abrupt rise in PaCO2 during HFOV in an otherwise stable patient may be the result of airway obstruction Suction catheter should be passed immediately to ensure patency of ET tube May consider bronchoscopy
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