lung protective jet ventilation basic lung protective strategy for treating rds and air leaks with...
TRANSCRIPT
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Lung Protective Jet Ventilation
Basic Lung Protective Strategyfor
Treating RDS and Air Leakswith HFJV
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Lung Protective Positive Pressure Ventilation
1. Recruit collapsed alveoli.
2. Stabilize alveoli with adequate PEEP and MAP (mean airway pressure).
3. Maintain adequate ventilation as gently as possible.
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Lung Protective Ventilation with HFJV
Recruitment
Gentle Ventilation
IMV from Conventional Vent
Positive End-Expiratory (PEEP) & Mean Airway Pressure (MAP)
Stabilization
HFJV(Higher Rates Enable Smaller Tidal Volumes)
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Recruitment with IMV
IMV (“Sigh” breaths) are most useful
for alveolar recruitment, but
contraindicated when airleaks are
present.
The following experiment illustrates
why...
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Move your cursor over picture and click it to start video.
Double click here to continue on to next slide.
HFJV: 420 bpmPIP = 30CV:15 bpmPIP = 20
Note: CV breaths find the leak as path of least resistance while HFJV breaths continue to ventilate the other “alveoli”
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Stabilization with
PEEP / MAP
Alveoli must be kept open,
whether air leaks are present or not.
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HFJV = Most Gentle Ventilation
No other form of
ventilation uses smaller
tidal volumes.
HFJV uses the least overall
flow and airway pressure.
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5 Keys to Optimal Patient Management
1. Start HFJV while maintaining MAP.
2. Use CV to recruit collapsed alveoli and find optimal PEEP.
3. Monitor Servo Pressure to stay on track.
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5 Keys to Optimal Patient Management
4. Use HFJV rate to match lung time constants, encourage spontaneous breathing, & hasten extubation.
5. Wean to nasal CPAP.
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HFJV Patient Management # 1
Don’t let MAP fall when
initiating HFJV.
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Conventional HFJVP
ress
ure
Time
HFJV = Gentle Ventilation
PEEP and MAP enable Stabilization / Oxygenation
IMV enables Alveolar Recruitment
You must raise PEEP to maintain MAP for Stabilization / Oxygenation when starting HFJV.
Don’t Lose Mean Airway Pressure!
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HFJV Patient Management # 2
Use Conventional Ventilator
to Recruit Alveoli and
Find Optimal PEEP
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Alveolar Recruitment
Open collapsed alveoli with CV “Sigh” breaths.
V
P
Critical Opening Pressure
5
Big breaths open collapsed alveoli easier than little breaths.
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CV + Low PEEP = Atelectrauma
V
P5 8
PEEP
Critical Closing Pressure
Stabilize with PEEP
Keep open alveoli from collapsing
PEEP = 5 does not work when Critical Closing Pressure = 8.
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Find & Set Optimal PEEP
V
P5 9 25
Start HFJV and lower CV rate to 5 while keeping alveoli from collapsing by maintaining MAP with increased PEEP :
7
Maintain CV = 5 bpm& adjust FiO2 to stabilize SaO2 at 90%.
PEEP
Then switch CV to CPAP mode to test PEEP. Maintain HFJV at this PEEP level, weaning FiO2 to maintain target SaO2 until FiO2 ~ 30%.
Wean HFJV PIP to maintain target PCO2 .
If SaO2 falls, increase PEEP as necessary to keep SaO2 stable with HFJV + CPAP.
Does SaO2 fall when 5 IMV breaths CPAP?
Assume you started with CV and PEEP = 5, MAP = 10:
MAP
10
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HFJV Patient Management # 3
Monitor Servo Pressure• If S.P. you may need to wean PIP
to keep PaCO2 and pH in target range.
• If S.P. you may need to suction, re-position ETT, or treat bronchospasms or pneumothoraces…
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Reacting appropriately to Servo Pressure changes will enable continuous
Lung Protective HFJV.
V
P
Critical Closing Pressure
Gentle, open-lung, lung-protective ventilation …
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HFJV Patient Management # 4
Wean to nasal CPAP.
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As ventilation improves:
1. Reduce HFJV PIP first.
2. Reduce HFJV Rate to encourage spontaneous breathing.
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HFJV Rate I : E
600 bpm 1 : 4
420 1 : 6
360 1 : 7
300 1 : 9
240 1 : 12
More time for spontaneous
breathing!
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Warning
Reducing PIP for PCO2
also reduces MAP.
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0
20
15
10
5
25
PEEP
P
Time
Reducing PIP Reduces VT (PaCO2 )
and MAP (PaO2 )PIP
MAP
HFJV Waveform
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0
20
15
10
5
25
Paw
PIP
P
Time
PEEP
Reducing PIP and Raising PEEP ( VT , PaCO2 )
keeps MAP ( and hopefully PaO2 ) constant.
How can one keep MAP constant?
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What if patient is hyperventilated &
hypoxemic?
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0
20
15
10
5
25
PMAP
PEEP
Time
PIP
Increasing PEEP while keeping PIP constant
raises MAP ( PaO2 ) & decreases VT ( PaCO2 ).
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As oxygenation improves:
1. Wean big breaths first.(Get CV into CPAP mode.)
2. Wean FiO2 before PEEP/MAP.
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Wean to Nasal CPAP
You may want to offer a short trial of low rate CV or endotracheal CPAP with Jet in Standby before extubation to gauge patient’s readiness…
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5
10
15
20
0.0 0.5 1.0
Time, seconds
cm H2O
P
2.01.5
It’s time to extubate when…
Patient is breathing spontaneously.HFJV PIP < 15, PEEP < 8, FiO2 < 0.3
Set Nasal CPAP = HFJV MAP
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Questions?
- www.bunl.com- 800-800-HFJV
(Available 24/7)
Visit our website or give us a call: