Pediatric Ventilation

Lynn MacIsaac
BC Children’s Hospital
Thompson Rivers University
 CASE HISTORY
7-year old, previously healthy, 25-kg
girl experienced severe crushed-chest
injury while she was sitting under a
large concrete divider in a movie theater
lobby. The concrete came loose and
fell on her.
 Initial Mechanical Ventilation
• Ventilation extremely difficult both
intra- and post-operatively.
• Extremely poor compliance.

PCO2  285 and pH  6.65

 Siemens Servo 300 C

PRVC: VT < 10 cc/kg, PEEP +5,

Rate 25-35. Result = PIP > 60.
Pressure Control: PIP 35 - 40, Rates up to
140.
Result = VT < 25 cc (< 1 mL/kg) and
PaCO2 > 200.
Intraoperative Findings
• Intraoperatively - large tear of
membranous trachea involving
right and left mainstem bronchi

• Prolonged and
difficult surgery
 DIAGNOSIS

• Bilateral Pneumothoraces
• Subcutaneous Emphysema
• Lacerated Liver
• Tracheal Tear
 IN EXTREMIS!!

• pH from 6.80 - 6.65

• PCO2 from 195 to 285 mm Hg
• Frequent desaturations
• Hemodynamic instability: fluid
resuscitation and dopamine 20 mg/kg/min.
 Options
• Oscillation ventilation
– Worried about the air leak and effects of MAP
on trachea
• ECMO
– not available at BCCH at the time too unstable
to transport
• Jet ventilation
– One of the key indications for use is air leaks
 Why HFJV?
1. Very Gentle
• Small Tidal Volumes
• Low Airway Pressures

2. Easy to Use, Like Conventional Ventilation

• Same principles of gas exchange
• Same setting changes produce same blood
gas changes
 Why HFJV?
3. Combined HFJV / CV Great Versatility,
especially with non-homogeneous lung
disorders.

4. Works when nothing else will on an air

leak situation!
 HFJV Trial ?
• HFV Rate: 240
• CV Rate: 30 CPAP
• CV PIP HFV PIP: 60+ 42

• PEEP / CPAP: 10 14
 HFJV Results
1hr - 15 min:
PaCO2 285 72
pH 6.65 7.21
2hr - 10 min:
PaCO2 26 mmHg
pH 7.52
 RECOVERY
Day 6: Changed to conventional ventilation

Day 8: Repeat bronchoscopy revealed good healing of

tear w/o granuloma or tracheitis

Day 10: Chest tubes out

Day 11: Extubated

Day 16: Discharged home

 Ventilator-associated
pneumonia (VAP)
• is a sub-type of
hospital-acquired pneumonia (HAP) which
occurs in people who are receiving
mechanical ventilation
• definition of VAP is restricted to patients
undergoing mechanical ventilation while in
a hospital
 Checks
• Head of the bed 40 degree head elevation
• NG or OG in proper place
• ETT cuff inflated
• Mouth care
• No instillation with suctioning
• Ventilator tube position
• Done every 3 hours
 VAP
• The diagnoses of VAP is difficult but
usually requires:
– a new infiltrate on chest x-ray
– two or more of: fever of >38.3°C
– leukocytosis of >12 × 109/m
– purulent tracheobronchial secretions
– and/or reduction in gas exchange
 Why did Jet work when
nothing else would?
• Started early, before damage was
irreversible
• Jet capabilities fit pathophysiology
• Jet was implemented with proper
strategy
• Sometimes the magic works…
 Starting early enough…

• Why is it that some people wait until a

patient has one or two feet in the grave
before they try HFJV?
• What does waiting cost?
Success with Pediatric ARDS*

• 29 children (0.03 – 4 yrs.) treated

with HFJV for ARDS complicated
by pulmonary barotrauma
• 20/29 survived (69%)

* Smith DW, et al. Ped Pulm, 1993; 15: 279-286.

Success with Pediatric ARDS*

Only statistical difference between

survivors and non-survivors, time
on CV before starting HFJV:
Survivors: 3.7 ± 2.1 days
Non-survivors: 9.6 ± 4.5 days
p < 0.05

* Smith DW, et al. Ped Pulmonol., 1993; 15: 279-286.

Jet capabilities & pathophysiology …
Stanford patients had pulmonary
barotrauma > 24 hrs on CV.
• Air leaks
• Pulmonary edema
• Poor lung compliance
• Airway inflammation & gas trapping
• Increased Pul. Vascular Resistance
 HFJV vs. CV
In comparison to CV, HFJV:
• HFJV uses much smaller tidal
volumes (1-2 ml/kg),
• HFJV uses much lower distending
pressures, and
• HFJV allows safe use of higher
PEEP.
So what’s different?
PRESSURE WAVEFORM COMPARISON
Three Ventilators, Same Blood
Gases
Tracheal Pressure, cm H2O

20

15

10 HFOV

5 CV
HFJV
0
0 0.2 0.4 0.6 0.8 seconds

Time Paw

Boros, et al. Ped Pulm. 1989; 7:35-41

Flow Streaming Reduces Effective Dead Space!
Inspired gas streams into the airways
with high velocity, but low pressure.
It swirls down the
CO 2 airways, splitting at bifurcations, always
CO2

seeking the path of least

resistance in the center
of the airways. The train of
tiny tidal volumes moves high
pO2 gas close to alveoli, while
CO2 is compressed against
airway walls.
 “Patient Box”

I’m very quiet…

LifePort ET tube adapter
Pressure Monitoring Line

15-mm Connector

Jet Injection Port

Jet Port Cap

ET Tube Connector
 The LifePort Adapter

Pressure
Jet Monitoring
Port Port

Inspired gas is PIP is measured

injected down the here and filtered to
ETT in high velocity estimate PIP at the
spurts. tip of ETT.
 How is HFJV Different?
1. HFJV squirts VTs into the lungs much
faster than CV or HFOV.
2. HFJV uses very short I:E ratios (1:4 to
1:12 at 660 to 240 bpm).

3. HFJV can use lowest Paw of all forms of

assisted ventilation, due
to short I:E and passive exhalation.
 Pulmonary Interstitial Emphysema
A Non-Homogeneous Disorder

Tension PIE restricts

alveolar expansion.

Interstitial gas
increases airway
resistance upstream
from leak site.
 HFJV Gas Distribution in
Non-Homogeneous Lung Disease

PIE
High airway resistance
upstream of injury
limits ventilation,
promotes healing
RDS
More ventilation since
small VTs not affected by
atelectasis, low lung
compliance

Raw CL
Problem Problem

HFJV: less gas to injuries, more gas for RDS!

 PIE Study Conclusions
• HFJV leads to resolution of PIE more fre-quently
than does rapid rate, short TI CV.
• HFJV results in more rapid improvement of PIE
compared to CV.
• HFJV provides better gas exchange at lower
airway pressures compared to CV.
• HFJV does not increase the incidence of important
complications.
• HFJV improves survival in babies with PIE.
(Keszler M, Donn SM, Bucciarelli RL, et al., 1991)
 What difference does a high
velocity of inspiration make?

1. Gas distribution avoids areas of high

airway resistance, which aids in treatment
of lower airway leaks.
2. It makes treatment of gross, upper
airway leaks possible.
 Passive, Long Exhalations
1. Airways stay open with CO
2

low Paw. CO
2

CO
2

2. Exhaled gas swirls

CO2
out along airway CO
2

walls, facilitating
mucociliary
clearance.
 Patient Management on
HFJV

How to Optimize Ventilation

(PaCO2) and Oxygenation
(PaO2)
 The Jet in Tandem with CV
Ventilation
Oxygenation
Jet
CV

PEEP
Valve

LifePort adapter
 HFJV + CV.
• Jet provides ventilation.
• CV provides three things…
1. PEEP control,
2. big breaths for alveolar
recruitment or airway dilation,
3. gas for spontaneous breathing.
HFV ∆P (pressure amplitude) is
key to controlling PaCO2
because:

2
VCO2  f x VT
Drazen JM, et al. Physiol. Rev. 64: 505, 1984.
Fredberg, JJ. Acta Anaesthesiol. Scand. 33: 170, 1989.
Oxygenation: 2-Step Process
Step One:
• Stabilize alveoli with
adequate PEEP.
Step Two:
• Recruit collapsed alveoli
with IMV when atelectasis
is present.
 Using IMV to recruit
collapsed alveoli is a
temporary maneuver.
Do not continue to use
high CV rate with high
PEEP once oxygenation
improves!
 Finding Optimal PEEP During HFJV *
Start with PEEP appropriate for IMV
IMV Rate = 5-10 bpm
Note current SaO2 on pulse oximeter

Flip IMV to CPAP mode

NO
Does SaO2 drop? PEEP is high enough, for the moment
(1- 5 min.)

YES
Flip back to IMV if desired, but use
PEEP is too low
lower settings. (Rate = 1-3; half PIP.)

Flip back to IMV

Rate = 5 - 10 bpm YES Does FIO2
need to be increased?
(some time later)
Increase PEEP by 1-2
NO

Wait for SaO2 to return Keep PEEP at this level

to acceptable value until FiO2 < 0.40
(It may take >30 min.)
* Don’t be surprised if PEEP = 7-12.
 HFJV for Chronic Lung Disease

Children’s of LA Retrospective Study*:

10 Infants with CLD & Pneumonia/Sepsis,
> 4 weeks old, on 100% O2 and HFOV

* Friedlich et al, J. Maternal-Fetal & Neonatal Medicine

2003; 13:398-402
 HFJV after HFOV for CLD

• 9/10 survived and discharged on O2

• One patient expired from septic
shock within 3 hrs of HFJV initiation
• Mean time on HFJV = 172 hours
(one patient on HFJV for just 1 hour)
Nitric Oxide + HFJV works
well for PPHN
INOvent Jet
* CV
"T" into
GAS OUT
tubing

INOvent injector module

LifePort adapter
Jet Circuit "Y"
connector
Sampling line to analyzer
Nursing Considerations

• Suctioning
• Positioning
• Weaning
INO via HFJV
 Suctioning Techniques
• Put Jet in Standby and do it the same way
you always do…
• Leave Jet running:
− silence alarms, DON’T PUSH RESET!
− instill irrigation fluid into adapter Jet Port
(temporarily disconnect, instill, re-
connect to spray it down tube)
− Suck all the way in and all the way out.
 Suctioning Frequency
• If Servo Pressure slowly falls over
time, suction when:
− PaCO2 rises, or
− SaO2 falls, or
− chest wall movement diminishes.
 After Suctioning
• Give manual breaths for re-expansion,
as necessary.
• Use CV Manual Breath button!
 Weaning
• Can go straight to nasal CPAP…

• Can go back to Conventional Ventilation

− Keep in mind: CV VT >> HFJV VT
− Try to stay on HFJV until you can
wean to CV at Rate < 20 bpm,
PIP < 15 cm H2O.