High Frequency Ventilation

Is a ventilatory strategy that utilizes a form of

mechanical ventilation that combines very
high respiratory rates (>60 breaths per
minute) with tidal volumes that are smaller
than the volume of anatomic dead space. The
clinical rationale for this type of ventilation is
that gas exchange is optimized by utilizing
small tidal volumes with minimal alveolar
stretch.
 There are three basic types of HFV
High Frequency Jet Ventilation
High Frequency Oscillatory Ventilation
High Frequency Percussive Ventilation
HIGH FREQUENCY OSCILLATORY VENTILATION
High frequency oscillatory ventilation
(HFOV) uses a reciprocating diaphragm to
deliver respiratory rates in the range of 3 to
15 Hz (up to 900 breaths per minute)
through a standard endotracheal tube.

Since HFO uses reciprocating pumps or

diaphragms both expiration and inspiration
are active processes during HFO.
 HFO Vts are approximately 1 to 3 mL/kg at fs
up to 2,400 breaths/min.

The operator sets the f, the I/E (typically

approximately 1:2), driving pressure, and
mean airway pressure (MAP).
Advantages
itappears as though HFOV prevents the release of
inflammatory chemical mediators in the lung,
resulting in less lung injury than is seen with
conventional ventilation.

when used in conjunction with surfactant

replacement therapy during the first hours of life, the
incidence and severity of bronchopulmonary
dysplasia (BPD) may be reduced.

when applied early to maintain ventilation with

optimal lung volume, oxygenation is increased in
acute stages of RDS.
Complications
The ability of HFOV to oxygenate the blood is not
as good as with other methods.
This often requires the use of high levels of PEEP,
often in excess of 15 cm H2O.
Combined with evidence that HFOV causes
hyperinflation of the alveoli, high levels of PEEP
may compromise cardiac output and lead to a
higher risk of developing barotrauma.

There are several technical problems encountered

in the use of HFOV.
One problem is in the measurement of pressure at
the distal end of the endotracheal tube.
It is likely that alveolar pressures are quite
different from those measured at the carina.
An additional problem is a general lack of HFOV
devices and training for their use in level I and
level II nurseries.
Initial HFOV Settings
Mean Airway Pressure (mPaw)
The mPaw affects mostly the oxygenation of the patient.
The initial setting of mPaw on HFOV should be based on
the mPaw during conventional ventilation.

Flow
infants weighing more than 2,000 g.
20L/min
infants less than 2,000g
10 to 15 L/min should be adequate.
Power
The power setting determines the amplitude of oscillation (P) and
thus the tidal volume and degree of ventilation.
In HFOV, the tidal volume produced by the power setting is less than
the deadspace volume.
The CO2 is drawn out actively during oscillation. Initially, the power
setting should be increased in increments of 2 to 4 cm H2O unless
the PCO2 demands require dynamic changes for increasing or
decreasing the amplitude.
Changes in the power setting will affect the mPaw, thus requiring
readjustment of the mPaw.
The piston should be centered continuously when changes are made.
Frequency
The initial frequency setting is 8 to 15 Hz depending on
the size of the infant and the diagnosis.
The frequency may need adjustment when changes
are made to amplitude or mPaw.
The piston should be centered continuously when
changes are made. Increasing the power (amplitude of
oscillation or P) or decreasing the frequency (Hz)
increase delivered tidal volume and decrease PaCO2.
Inspiratory time %
The inspiratory time % determines the I:E ratio and is
usually set at 33%.
This setting provides an I:E ratio of 1:2.
This parameter is not routinely changed.

FiO2
The initial FIO2 may be set at 100%.
After stabilization of the patient, the FIO2 is titrated to
keep SpO2 between 90% and 95%.
 A study conducted by Peter et. al., entitled High-
frequency oscillatory ventilation for adult respiratory
distress syndrome states that High-frequency
oscillatory ventilation is both safe and effective in
adult patients with severe ARDS failing conventional
ventilation. A lung volume recruitment strategy during
high-frequency oscillatory ventilation produced
improved gas exchange without a compromise in
oxygen delivery. These results are encouraging and
support the need for a prospective, randomized trial
of algorithm-controlled conventional ventilation vs.
high-frequency oscillatory ventilation for adults with
severe ARDS. (Crit Care Med 1997; 25:937-947)
Randomized study of high-frequency oscillatory ventilation in
infants with severe respiratory distress syndrome

The researchers conducted a multicenter, prospective,

noncrossover, randomized study to determine whether
high-frequency oscillatory ventilation (HFOV) would
decrease the development or progression of air leak
syndrome in infants with severe respiratory distress
syndrome.
Air leak syndrome was defined as pulmonary interstitial
emphysema or gross air leak such as pneumothorax.
Infants were eligible for study entry if they were less
than 48 hours of age and had severe respiratory
distress syndrome, defined by peak inspiratory pressure
or the presence of air leak syndrome. Infants who
weighed 0.5 kg at birth were randomly assigned to
receive either conventional ventilation (CV) or HFOV.
 HFOV was provided by a ventilator that operated at 15 Hz, with a 1:2
inspiratory/expiratory ratio and no background tidal breaths.
Severity of pulmonary interstitial emphysema was scored independently
by two neonatologists unaware of the infants' ventilatory group. Gross air
leak severity was scored according to the number of chest tubes required
and duration of air leak. Eighty-six infants received HFOV; 90 received CV.
During the first 24 hours of the study, patients in the HFOV group received
significantly higher mean airway pressure and lower inspired oxygen
concentration, had significantly lower arterial carbon dioxide tension, and
had a higher ratio of arterial to alveolar oxygen tension.
When the HFOV and CV groups were compared with control for birth
weight strata, study site, and inborn versus outborn status, HFOV
significantly reduced the development of air leak syndrome in those
patients who entered the study without the syndrome.
The researchers concluded that HFOV, when the strategy employed in this
study is used, provides effective ventilation, improves oxygenation, and
significantly reduces the development of air leak syndrome in infants with
severe respiratory distress syndrome.

High Frequency Jet Ventilation

HFV delivered using a jet of gas.

High frequency jet ventilation (HFJV) is provided
by theBunnell Life Pulse High-Frequency
Ventilator.
It is initiated by inserting a catheter into the
lumen of the endotracheal tube.
A small (14 to 16 gauge) cannula is then
connected to a specialized ventilator.
An initial pressure of approximately 35 psi drives
the jet of gas from the cannula
initial RR of 100 to 150 breaths per minute
inspiratory fraction less than 40%.
 Applied positive end-expiratory pressure (PEEP)
and/or sigh breaths are added if needed via
conventional ventilator.
HFJV employs an endotracheal tube adaptor in
place of the normal 15 mm ET tube adaptor. A
high pressure jet of gas flows out of the
adaptor and into the airway.
This duration of the jet is very briefabout 0.02
secondsand at high frequency: 4 to 11 Hz.
Tidal volumes 1 ml/kg are used during HFJV.
Aerosolized saline solution in the inspiratory
circuit is used to humidify the inspired air.
 Exhalation is passive.
Jet ventilators utilize various I:E ratios
between 1:1.1 and 1:12to help achieve
optimal exhalation.
Conventional mechanical breaths are often
used to aid in reinflating the lung.
Optimal PEEP is used to maintain alveolar
inflation and promote ventilation-to-perfusion
matching.
 A conventional ventilator is always run in
tandem with the jet to generate the PEEP and
sigh breaths.
Expiration on HFJV is passive from elastic recoil.
A special ET adaptor is used during HFJV. This
adaptor has a jet port through which the high
frequency jet pulses are introduced and a
pressure monitoring port for determining the
delivered pressures.
Currently, HFJV is utilized primarily in the
neonatal population.
Indications
The Bunnell Life Pulse High-Frequency Ventilator is
indicated for use in ventilating critically ill infants.
Infants studied ranged in birth weight from 750 to
3529 grams and ingestation agefrom 24 to 41
weeks.
The Bunnell Life Pulse High-Frequency Ventilator is
also indicated for use in ventilating critically ill
infants with Respiratory Distress Syndrome(RDS)
complicated by pulmonary air leaks who are, in the
opinion of their physicians, failing onconventional
ventilation. Infants of this description studied
ranged in birth weight from 600 to 3660 grams and
ingestational agefrom 24 to 38 weeks
Contraindications

High-frequency jet ventilation is

contraindicated in patients requiring tracheal
tubes smaller than 2.5mm ID.
 A study conducted by Fort et. al., entitled
Use of high-frequency jet ventilation in neonates
with hypoxemia refractory to high-frequency
oscillatory ventilation.
OBJECTIVE:
To describe the response to high-frequency jet ventilation in infants with hypoxemic
respiratory failure unresponsive to high-frequency oscillatory ventilation.
METHODS:
This was a retrospective analysis of chart records on demographics, ventilator settings,
blood gas analysis and calculated oxygenation index prior to and during the first 7 days of
high-frequency jet ventilation in ten consecutive infants.
RESULTS:
Before the initiation of high-frequency jet ventilation, the ventilatory mean airway pressure
(MAP; cmH2O), fraction of inspired oxygen (FiO2) and oxygenation index on high-frequency
oscillatory ventilation were 14.3 +/- 1.3, 0.97 +/- 0.02 and 29 +/- 5, respectively. Three
hours after the initiation of high-frequency jet ventilation, the oxygenation index improved to
18 +/- 4 (p < 0.001) and the improvement was sustained during the study period. By 6 h of
high-frequency jet ventilation, the FiO2 decreased to 0.62 +/- 0.09 (p < 0.01) and, by 1-3 h
of ventilation, the MAP decreased to 10.9 +/- 1.3 (p < 0.01). The improvement in FiO2
persisted for 7 days while, although the MAP remained lower throughout the study, the
improvement in MAP failed to reach statistical significance after 72 h. No significant changes
in pH, pCO2, or pO2 before or during high-frequency jet ventilation were noted.
CONCLUSION:
High-frequency jet ventilation improves hypoxemic respiratory failure unresponsive to high-
frequency oscillatory ventilation in infants. These findings suggest that not all high-
frequency ventilatory devices yield the same clinical results.
High Frequency Percussive Ventilation

High frequency percussive ventilation (HFPV)

provides subtidal volumes in conjunction with
cycled, pressure-limited controlled mechanical
ventilation (ie, pressure control ventilation,
PCV).
It can be conceptualized as HFOV oscillating
around two different pressure levels, the
inspiratory and expiratory airway pressures.
HFPV improves oxygenation, improves
ventilation, and lowers airway pressures (peak,
mean, and end-expiratory), compared to other
modes of mechanical ventilation. 7
 HFPV is delivered via the volumeric diffusive
ventilator (VDR).
The VDR is classified as pneumatic-driven,
time-cycle, pressure-limited, biphasic
oscillatory breaths, and exhalation occurs
passively.
Mean airway pressure is a product of the peak
airway pressure, inspiratory time length, pulse
frequency rate, and PEEP setting.
 HFPV is possible because of a device called a
Phasitron.
The Phasitron is an inspiratory and expiratory
valve located at the end of the endotracheal
tube. High-pressure gas drives the Phasitron
to deliver small tidal volumes at a high
frequency (200 to 900 beats per minute),
superimposed on the inspiratory and
expiratory airway pressures of PCV.
The PCV is typically delivered at a respiratory
rate of 10 to 15 breaths per minute.
 HFPV does not always require pharmacologic
paralysis. In addition, it can clear secretions
very effectively secondary to an internal
mucokinesis. Currently, HFPV is utilized in all
patient populations and is standard of care in
regional burn centers for ventilatory support
of patients with inhalation injury.8
 A study conducted by Bargues et. al., entitled
High-frequency percussive ventilation at
altitude: study in a hypobaric chamber with a
mechanical test lung statesHFPV can be
safely used at altitude, provided that the
percussionairedisplayed parameters are used
to manually adjust settings in order to avoid
exposing patients to volutrauma or
barotrauma during ascent, and to major
hypoventilation and alveolar collapse during
descent. The high oxygen consumption is
currently the main limit to its use for long-
range aeromedical evacuations.