Lungs as a two compartment model First compartment: AIRWAYS. Do not participate in gas exchange referred as anatomic dead space
Second compartment: ALVEOLAR UNITS responsible for gas exchange Elements of HFV Use of supraphysiologic ventilatory rates above 60 rpm
Use of tidal volume smaller than the anatomic dead space Types of HFV High Frequency Oscillatory Ventilation High Frequency Jet Ventilation High Frequency Positive Pressure Ventilation Mechanisms of gas transport in High Frequency Ventilation Direct alveolar ventilation Pendelluft effect Convective streaming Augmented (Taylor) dispersion Cardiogenic mixing Molecular diffusion Indications for HFV Neonatal Respiratory Distress Syndrome Persistent Pulmonary Hypertension Neonatal Meconium Aspiration Syndrome Congenital Diaphragmatic Hernia Neonatal Lung Hypoplasia Neonatal Air Leak Syndrome with PIE Pediatric ARDS RSV Pneumonia (not bronchiolitis!!) Contraindications for HFV Obstructive Airway Disease Asthma, RAD, Emphysema, Bronchiolitis
Cardiovascular System Dysfunction
Shock Switch from conventional to HFV Goal of HFV: maximize oxygenation and ventilation with adequate lung volume while minimizing barotrauma and oxygen toxicity. Indications: increased FiO2 and Paw with poor saturations. (O2 index) Initial settings for HFOV FiO2: 1.0 Mean Airway Pressure: 2-6 cm H2O higher than conventional ventilation. Bias flow: 15 L/min Frequency: 10-15 Hz in neonates, 6-10 Hz in older patients. Inspiratory time: 33 % Power: 2.0-4.0 (amplitude 20-30 cm H2O) Oxygenation management Increase MAP until saturations reach >90% Then, decrease FiO2 progressively down to < 0.60. If saturations drop below 90% then increase MAP. Factors that affect oxygenation in HFV Main factors: Mean Airway Pressure (Paw) FiO2
Circumstantial factors: Inspiratory time Frequency (Hz) Ventilation management Maintain PaCO2 of 40-50 Maintain pH of >7.30 Permissive hypercarbia: allows for higher PaCO2 and lower pH Factors that affect ventilation in HFV Amplitude pressure (power) Bias flow Frequency (Hz) Inspiratory time Monitoring the patient on HFV Frequent observation of chest symmetry Observation of chest vibration Evaluation of lung expansion on CXR Check capillary refill, skin color, temperature. Comparing central with peripheral pulses Monitoring of EKG tracing Care of the patient on HFV Respiratory care: suctioning hand bagging Chest PT Patient Positioning Analgesia, sedation, and neuromuscular blockade Parent-caretaker interactions
Complications of HFV Lung Overdistention and Air Leak Syndrome Cardiovascular depression Necrotizing Tracheobronchitis Patient Disconnection Unplanned Extubation
Switch back to conventional ventilator HFOV can be weaned gradually to CPAP by lowering the Amplitude. (in small infants)
Switch to conventional once: (in pediatric pts) MAP < 15 cm H2O FiO2< 0.50 adequate gas exchange improving pulmonary function Successful switch from HFV to conventional ventilation Adequate oxygenation and ventilation FiO2 <60 rate<30 bpm PIP < 30 cm H2O New trends for HFV HFV and Nitric Oxide HFOV and Surfactant HFOV and Partial Liquid Ventilation HFV in adults Summary HFOV, HFJV, HFPPV Indications Contraindications Oxygenation management Ventilation management Monitoring and care of the patient Complications