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    HFOV High-Frequency-Oscillatory-Ventilation

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    JZ
    The document provides information about using high frequency oscillatory ventilation (HFOV) for a preterm infant requiring emergent surgery. It describes how HFOV works, appropriate indications and contraindications, starting settings, troubleshooting poor oxygenation or ventilation, and considerations for using HFOV during transport or surgery. HFOV applies small tidal volumes at high frequency to improve gas exchange when conventional ventilation is failing. It can be used during surgery while continuing specialized lung-protective ventilation.

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    HFOV High-Frequency-Oscillatory-Ventilation

    Uploaded by

    JZ
    196 views22 pages
    The document provides information about using high frequency oscillatory ventilation (HFOV) for a preterm infant requiring emergent surgery. It describes how HFOV works, appropriate indications and contraindications, starting settings, troubleshooting poor oxygenation or ventilation, and considerations for using HFOV during transport or surgery. HFOV applies small tidal volumes at high frequency to improve gas exchange when conventional ventilation is failing. It can be used during surgery while continuing specialized lung-protective ventilation.

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    High Frequency Oscillatory Ventilation

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    HFOV high-frequency-oscillatory-ventilation

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    The document provides information about using high frequency oscillatory ventilation (HFOV) for a preterm infant requiring emergent surgery. It describes how HFOV works, appropriate indications and contraindications, starting settings, troubleshooting poor oxygenation or ventilation, and considerations for using HFOV during transport or surgery. HFOV applies small tidal volumes at high frequency to improve gas exchange when conventional ventilation is failing. It can be used during surgery while continuing specialized lung-protective ventilation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    196 views22 pages

    HFOV High-Frequency-Oscillatory-Ventilation

    Uploaded by

    JZ
    The document provides information about using high frequency oscillatory ventilation (HFOV) for a preterm infant requiring emergent surgery. It describes how HFOV works, appropriate indications and contraindications, starting settings, troubleshooting poor oxygenation or ventilation, and considerations for using HFOV during transport or surgery. HFOV applies small tidal volumes at high frequency to improve gas exchange when conventional ventilation is failing. It can be used during surgery while continuing specialized lung-protective ventilation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 22
    At a glance
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    HFOV can provide lung protective ventilation and oxygenation when conventional ventilation is inadequate. It requires monitoring blood gases and adjusting MAP and amplitude settings.

    Indications for HFOV include failure of conventional ventilation, pulmonary hypertension, air leak syndromes, and failure of oxygenation.

    An oscillator uses a diaphragm or piston to generate pressure oscillations at high frequency (3-15Hz) to ventilate the lungs, delivering very small tidal volumes (<3ml/kg).

    High Frequency Oscillatory

    Ventilation (HFOV)
    James Xie, MD
    Pediatric Anesthesiology Fellow
    Stanford Children’s Health
    11/18/2019
    - Sunday afternoon: you are called by the

    Case Presentation general surgery team for an emergent ex-lap


    for suspected necrotizing enterocolitis

    - Patient is a former 25+5 week infant born


    after unstoppable preterm labor, now corrected
    to 29+2

    - One day prior, patient was put on HFOV due to


    worsening hypercarbia (arterial PCO2 96)
    despite high conventional ventilator settings
    (Vt 5ml/kg, RR 50, PEEP 7)

    - Current oscillator settings are: MAP 14,


    Amplitude 32, Frequency 12, I-Time 0.33, FiO2
    31% and recent ABG: 7.25/66/70

    - What is your ventilation strategy for the


    operation?
    So many questions...

    - Why did the NICU put the baby on the oscillator?


    - Is this the same or different than high frequency jet ventilation?
    - How does an oscillator even work?
    - Can you perform surgery while a patient is on the oscillator?
    - How do I manage an oscillator? What are all those knobs for?
    - Can I just switch back to a conventional ventilator?
    - Is the oscillator working?
    - Can I transport to the OR on an oscillator?
    - Can I use nitric oxide while on HFOV?
    - Can anyone help me??
    Indications for HFOV
    When to use HFOV:

    1. Persistent Pulmonary Hypertension of the Newborn


    2. Meconium Aspiration Syndrome
    3. Air leak syndromes: pneumothorax, pulmonary interstitial emphysema
    4. Severe Respiratory Distress Syndrome
    5. Pulmonary hypoplasia
    6. Failure of conventional ventilation (plateau pressures ≥ 30-35 cmH20 with tidal
    volumes of 5-7 ml/kg and severe respiratory acidosis, pH< 7.1)
    7. Failure of oxygenation (e.g. ARDS)
    a. SpO2 < 90%, or
    b. PaO2/FiO2 < 150, despite FiO2 > 60% and optimal PEEP, or
    c. Oxygenation index (OI) > 15 (where OI = [MAP x FiO2(%)] / PaO2)
    Contraindications to HFOV

    When not to use HFOV (relative contraindications):

    1. Obstructive airway disease (HFOV can lead to severe air trapping if used improperly)
    2. Traumatic brain injury / intracranial hypertension (high MAP can lead to decreased
    venous return, reduced cerebral perfusion)
    3. Hemodynamic compromise (especially if unresponsive to fluids/vasoactives; )
    ...consider VA ECMO!
    Side Note on Jet Ventilation
    - HFOV = High frequency oscillatory - HFJV = High frequency jet ventilation
    ventilation (3-15Hz RR, TV ≤ 1-3ml/kg) (4-11Hz RR, TV ≤ 1ml/kg)
    - Via movement of an electromagnetic - Via a pneumatic valve, short jets of gas
    diaphragm or piston pump, pressure is are released into the inspiratory circuit =>
    generated in the ventilator circuit => expiration is passive (from elastic recoil)
    active inspiratory and expiratory - HFJV is used in conjunction with
    phases conventional mechanical ventilation, with
    - No sigh breaths for alveolar application of PEEP (sigh breaths)
    recruitment - can easily de-recruit - Differs from low frequency jet which uses
    - This is what we are talking about a manually triggered hand-held device
    today - Topics for another day!
    How does it work?
    - A constant distending airway pressure is applied
    (MAP), over which small tidal volumes are
    superimposed (Power/Amplitude) at a high
    respiratory frequency (measured in Hz)
    - Radial mixing (Taylor dispersion): enhances gas
    mixing with laminar flow (beyond bulk flow front)
    - Collateral ventilation: alveoli communicate
    directly with other nearby alveoli
    - Coaxial flow: net flow through centre of airway on
    way down, then on outside of airway on way up
    - Pendelluft ventilation nearby lung units have
    different time constants/impedance/phase lags
    - Cardiogenic mixing: internal ‘wobble’ of
    heartbeats transmitted to the molecules of gas
    within the lungs causes gas mixing
    How does it work?

    Image source: https://www.semanticscholar.org/paper/High-frequency-oscillatory-ventilation-(HFOV)-and-a-Stawicki-Goyal/1196df59f3d6e08db0db881e478c3a8629d43548/figure/4


    Intraoperative Use of HFOV
    - Yes, it’s been done!
    - Conditions operated on include: congenital diaphragmatic hernia, congenital cystic
    adenomatoid malformation, esophageal atresia, PDA, abdominal wall defect, NEC
    - Advantages:
    - HFOV minimizes lung movement and interference with the surgical field
    - Provides continuity in in perioperative ventilatory management
    - May minimize lung injury, especially in conditions with altered respiratory compliance
    - Limitations:
    - Lack of familiarity with HFOV by anesthesiologist
    - Can’t use inhalational agents (thus TIVA is recommended)
    - Routine capnography not possible (frequent blood gases, TCOM needed)
    - HFOV is loud and can hinder clinical exam (e.g. auscultation of heart sounds)
    SensorMedics 3100A/B HFOV

    - 3100A model:
    Approved by FDA in
    1991 for use in
    neonates, used for
    patients < 35kg
    - 3100B model: used
    for patients > 35kg

    - Approval for use in all


    pediatrics in 1995
    Reasonable Starting Settings
    - MAP (max ~ 40-45 cm H2O) - You will likely never adjust bias flow,
    - Neonates: 2-5 cm above MAP on CMV frequency, or I-time:
    - Infants/Children: 5-8 cm above MAP on - Bias flow (allowing further increase in MAP)
    CMV - < 1 year old: 15-25 L/m,
    - MAP, if starting immediately on HFOV
    - 1-8-year-old: 15-30 L/m
    - Neonates: 8-10 cm H20
    - Infants/children: 15-20 cmH20 - ≥8-year-old: 25-40 L/m
    - Amplitude/Power: adjust ΔP until there is - Frequency
    perceptible chest wall motion from the nipple - Preterm neonate: 15Hz (900 bpm)
    line to the umbilicus (AKA chest wiggle - Term neonate: 12Hz (720 bpm)
    factor). Initial settings might be: - Infant/Child: 10Hz (600 bpm)
    - Wt < 2.0 kg: 2.5
    - Wt 2.1 - 2.5 kg: 3.0 - Older child: 8Hz (480 bpm)
    - Wt 2.6 - 4.0 kg: 4.0 - Inspiratory time
    - Wt 4.1 - 5.0 kg: 5.0 - Usually set to 33% (I:E ratio of 1:2)
    - Wt 5.1 - 10 kg: 6.0 - Higher I-times may lead to air trapping
    - Wt > 20 kg: 7.0
    Can I switch to CMV?

    Patient may be able to tolerate conventional ventilation if your HFOV settings are:

    - MAP < 16-17 cm


    - FiO2 < 0.40 - 0.45
    - Power < 4.0
    - To convert to CMV, use a MAP 3-4 cm less than the MAP on HFV
    How do I know it’s working?

    - Patient SpO2 in the first 30-60 minutes of initiation can change dynamically
    - Adequate “jiggling” / “wobbling” / “chest wiggle” = patient is being ventilated
    - CXR to confirm that patient is not hyperinflated (MAP too high)
    - Transcutaneous CO2 monitoring can help trend CO2
    - Be aware of changes in lung compliance (e.g. secretions, neuromuscular
    blockade)
    - Consider suctioning +/- recruitment maneuver if O2 saturations remain low (but
    don’t suction too much because it will de-recruit the lungs; use a closed suction
    system if possible)
    Transcutaneous CO2 Monitoring

    - NICU respiratory therapists can assist with


    TCOM setup and use
    - Try to correlate with blood gas measurements to
    assess ventilation
    Quick Troubleshooting Guide

    Poor Oxygenation Over Oxygenation Under Ventilation Over Ventilation

    Increase FiO2 Decrease FiO2 Increase amplitude Decrease amplitude

    Decrease
    frequency** Increase
    Increase MAP* Decrease MAP (1-2Hz) if amplitude frequency**
    (1-2cmH2O) (1-2cmH2O) Maximal (1-2Hz) if amplitude
    Minimal

    * Consider recruitment maneuvers


    ** Changes in frequency are rare
    Why decreasing frequency increases TV

    - A lower frequency means


    there are fewer breaths per
    minute
    - This means the absolute
    inspiratory time is increased
    - If the I:E ratio is fixed at 1:2,
    the delta P for a given MAP
    will lead to a larger tidal
    volume being delivered
    Detailed guide for reference

    http://pages.carefusion.com/rs/carefusioncorporation/images/rc_3100a-pocket-guide.pdf
    Transport with HFOV?

    - Can I transport with HFOV?


    - Sort of? - It would require multiple
    tanks of O2 and a battery pack. If
    patient is too unstable for transport,
    consider doing the procedure at
    bedside
    - Moving a patient while on HFOV has
    been described in the literature (Lee
    et al 2012: Using the High
    Frequency Ventilation during
    Neonatal Transport)
    -
    Can I use nitric oxide with HFOV?

    - Yes! This is well described, especially in the PPHN population


    - Kinsella et al (1997): “Randomized, multicenter trial of inhaled nitric oxide
    and high-frequency oscillatory ventilation in severe, persistent pulmonary
    hypertension of the newborn” found that “treatment with HFOV plus iNO is
    often more successful than treatment with HFOV or iNO alone in severe
    PPHN”
    When in doubt...

    Ask for help!

    - Respiratory therapy team


    - RT Supervisor x 19613
    - OR RT on Voalte
    - NICU MDs
    Summary

    - HFOV is a useful ventilatory modality that can provide lung protective


    ventilation/oxygenation, especially when conventional ventilation is inadequate
    - HFOV can be safely and effectively continued intraoperatively
    - HFOV delivers an unknown tidal volume -> must check blood gases or trend TCOMs
    - Not wiggling = not ventilating
    - Higher MAP = more oxygenation
    - Higher amplitude (delta P or power) = more ventilation
    - It is highly unlikely you will need to adjust the I-time, frequency, or bias flow
    - Have a plan for transport (or not-transporting if patient is too unstable)
    - You can use nitric oxide, but not volatile agents. Plan on TIVA.
    - When in doubt, ask for help!
    References

    Wibble Wobble: High Frequency Oscillatory Ventilation (https://www.paediatricfoam.com/2019/02/hfov/)

    Bouchut JC, Godard J, Claris O. High-frequency oscillatory ventilation. Anesthesiology. 2004;100(4):1007-12.


    (https://anesthesiology.pubs.asahq.org/article.aspx?articleid=1943214)

    Klein, J. Management strategies with high frequency oscillatory ventilation (HFOV) in neonates using the SensorMedics
    3100A high frequency oscillatory ventilator
    (https://uichildrens.org/high-frequency-oscillatory-ventilation-hfov-neonates-3100A-ventilator)

    CareFusion. 3100A High Frequency Oscillatory Ventilator Pocket Guide


    (http://pages.carefusion.com/rs/carefusioncorporation/images/rc_3100a-pocket-guide.pdf)

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