David Albecker, BS, RRT-NPS, RPFT
RT Clinical Programs Manager
Winchester Medical Center
I have no financial interest in any device,
ventilator, corporation, method, rehab facility, or
therapy, mentioned in this presentation, and no
conflicts of interest.
David Albecker
(April, 2012)
• 58 year old female w/ Hx of COPD
and long-term tobacco use
• Bilateral CAP
• Septic shock → ARDS
–
–
–
–
–
BP ≈ 72/53
Febrile
pH ≈ 7.0
Thick, yellow pulm secretions
CXR – bilateral infiltrates all 4
lung quadrants
• NSTEMI during critical illness
complicated the case
•
•
•
•
•
IV Fluid Bolus
Multiple Antibiotics
Multiple Vasopressors
Heavy sedation
Increasing vent support w/ FiO2
of 1.0
• Changed to HFPV w/ VDR-4 on
day #2
• 6 days on VDR-4
– ABG improved
– FiO2 ↓ from 1.0 to 0.4
– CXR improved
• Refractory hypoxemia that was not improving with
conventional VC A/C
• Copious thick, yellow pulmonary secretions
• In our opinion, starting the VDR-4 in ARDS is better done
sooner than later
• APRV: the heavy sedation meant she would not breathe
spontaneously in the Thigh phase - important for CO2
clearance in APRV 1
• 3100B: active exhalation can cause gas trapping in severe
COPD pts2; & high, steady MAP may ↓ venous return/CO
Date: 2012
Ventilator
Mode
4/11
VC-A/C
4/11
VC-A/C
4/12
VC-A/C
4/12
HFPV
4/13
HFPV
4/14
HFPV
4/15
HFPV
4/16
HFPV
4/17
HFPV
4/18
VC-A/C
Rate
16
22
24
15
15
15
15
15
15
14
PEEP
12
12
12
12
12
12
12
12
8
10
Tidal Volume (ml)
400
400
500
FiO2
Percussive rate
(frequency/min)
0.9
0.9
1.0
500
0.9
600
0.85
500
0.7
500
0.6
500
0.5
500
0.4
500
Inspiratory Time (sec)
2
2
2
2
2
2
Expiratory Time (sec)
2
2
2
2
2
2
Peak Pressure
34
34
34
34
34
34
0.6
pH
PaCO2
7.04
64
7.02
67
7.15
40
7.25
45
7.37
36
7.32
37
7.26
46
7.30
43
7.32
42
7.45
41
PaO2
78
78
71
70
87
105
90
94
58
67
HCO3
17
17
14
20
21
19
20
21
22
28
BE
-14
-15
-14
-8
-4
-7
-7
-5
-4
+4
SaO2
Lactate
(mM/L)
Change made after
ABG
88%
2.8
87%
2.7
88%
91%
96%
98%
95%
1.2
96%
87%
94%
0.8 on
4/23
↑ rate to ↑rate to change to ↓ FiO2 to 0.85, ↓ FiO2 to ↓ FiO2 to ↓ FiO2 to ↓ FiO2 to
change
22
24, ↑tidal HFPV with ↓ percussive
0.7
0.6
0.5
0.4, ↓
back to
vol to
VDR-4
rate to
PEEP to VC- A/C on
500ml,
500/min
10, then 8
4/18
↑FiO2 to
1.0
3 pressure levels
• Add 5-10 cmH2O above PIP
for recruitment, but you
can add it without ↑PIP.
• “Gives the lung time to get
out of its own way”
– Slow-responding lung areas
• Philosophy Issue:
– Start w/ convective rise
– Add it only for recruitment
• VC A/C Settings:
–
–
–
–
–
VT = 6ml/kg IBW
Measured Pplat = ?
Rate = ?
PEEP = ?
FiO2 = ?
– Observe MAP & ABG
• Same for PC A/C except
use PIP rather than Pplat
• HFPV Settings:
– Consider MAP & ABG on
VC A/C
• PIP ≈ Pplat on VC A/C
– Good chest rise?
• PEEP ≈ PEEP on VC A/C
• I-Time = 2 sec
– E-Time = 2 sec
– Percussive rate=600/min
• FiO2 ≈ FiO2 on VC A/C
– Or 100% ( for transition)
• Convective Rise ?
• APRV Settings:
• The “Habashi way”
–
–
–
–
–
PHIGH = ?
PLow = 0
THigh ≈ 4-6 sec
TLow ≈ 0.8 sec
FiO2 = ?
– Observe MAP & ABG
• HFPV (VDR-4) Settings:
– Consider MAP & ABG
• PIP (AIP) ≈ PHIGH from APRV
– Good chest rise?
• PEEP ≈ 10-18
– Consider MAP & TLow exp flow
inflection point
• I-Time = 2 sec
– E-Time = 2 sec
– Percussive rate=600/min
• FiO2 ≈ FiO2 on APRV
– Or 100% for transition
• Pinch ETT
• Convective Rise?
• If pt not breathing
spontaneously, hard
to manage CO2 w/
APRV (heavily sedated
ARDS pt)
• This inflection pt
determines end-exp
lung volume in APRV
and, w/ MAP, helps
determine PEEP
(AEP) setting on the
VDR-4
•
Example: HFOV w/ 3100B
•
HFPV settings: remove cuff leak if it
was used w/ 3100B
•
Consider 3100B MAP when setting
VDR-4 PEEP
– MAP = 34 cm H2O
– Amplitude = 90 cm H2O
• Ventilation difficulty
– FiO2 = ?
– Hz = 3, 4, 5, or 6
– higher HFOV MAP → higher VDR-4 PEEP
• Ventilation difficulty
– % I-time = 33% (no concern)
– Cuff leak? Ventilation difficulty
•
VDR-4 will ventilate better than
3100B
•
Consider: tops of Amplitude pressure
spikes ≈ 79 cm H2O
– Bottom of Amp waveform could be -10
cm H2O!
•
Observe MAP & ABG
•
Monitron PIP may ≈ 3100B top of
Amplitude waveform
– AIP on VDR-4 (sustained PIP) will be
lower & clinically usable
– Good chest rise?
•
•
Match FiO2 (or 100% for transition)
I-time= E-time = 2 sec
– Percussive rate = 600
•
Convective Rise? Pinch ETT
• Observe MAP from 3100B
• Set VDR-4 PEEP (AEP on Multimeter) as high as
physician comfort allows
• Then adjust VDR-4 PIP (AIP on Multimeter) high
enough to get similar MAP as with 3100B
• Downside: If you underestimate PEEP, you will
overshoot on PIP in order to get target MAP – this
can be similar to ARDSnet fail VC A/C w/ low PEEP
and high tidal volume.
– Use ARDS Peep/FiO2 table rather than physician comfort
level
Dedicated Expiratory Half-Cycle on VDR-4 allows ETCO2 measurement
• Delivered tidal volume w/ VDR-4 allows
effective MDI/aerosol use
• Similar to VC or PC w/ conventional vent
• For MDI, time inhalation w/ inspiratory phase
– We place MDI adaptor between Phasitron and ETT/trach
• Aerosol med through Aerogen neb
– We place between insp limb of circuit and green insp port of
Phasitron, can also go between ETT/Trach and Phasitron
• Cuff Leak not required or used for ventilation w/
the VDR-4. Many better ways to ↓ CO2:
•
•
•
•
↑PIP (or ↓ PEEP if oxygenation allows) to ↑∆P
Add Convective pressure rise to ↑ ∆P
Decrease percussive rate from 600 to 450
(for COPD pt) Increase sinusoidal E-time allowing
for better exhalation
• ↑ PEEP
• Add Convective Pressure Rise (recruitment
maneuver)
• ↑ percussive rate from 600 to 750
• ↑ sinusoidal I-time (for pt without COPD)
which creates APRV-like pressure waveform
• ↑ FiO2
You must pay close attention to humidity
Passover + Aeroneb Solo – similar to disposable circuit + Passover
Phasitron w/ Aerogen neb
Complete circuit w/2 humidifiers
Aerogen
neb
FP
Passover
Pumps w/ Syringes
Aeroneb
Driver
Flolan pump
Saline pump
Connection to VDR-4: extension sets
from syringes attach to 3-way
stopcock @ Aeroneb Solo which
runs in continuous mode
Next 3 slides come from Brent Kenney’s presentation
We use this only as a back-up for Flolan in adult ICU
Adaptor placed between
Phasitron and ETT/trach
Adaptor w/ connecting tubes in
place
Blended gas to INOblender, then flow
out to adaptor @ Phasitron. Sample
line to INOmax sample line inlet port.
INO concentration measured in
standard way but adjustments made
@ INOblender
• Pathway that we follow
for the difficult-tooxygenate pt
• By the time we get to
ECMO, we are almost
always on the VDR-4
• We have a partnership
w/ VCU for ECMO pts in
adult ICU
• Experienced physician champion is a must (for us it
was Dr Barillo)
• We developed a HFPV protocol for adult ICU
• I did short, introductory inservices for as many ICU
nurses as possible (both shifts) on HFPV w/ VDR-4
• We did more complete inservices for all ICU RTs
• On a predetermined go-live date we started pt care
• Yearly mandatory education is a must for ICU RTs
• We have a protocol for the resp
care of the spinal cord injured
(SCI) pt
• After the initial acute phase,
how do you maintain lung
clearance and expansion longterm for vent-dependent SCI
pt?
• IPV + Cough Assist = Perfect!
Why IPV?
– Next slide…
• Kessler Institute for Rehabilitation was recently ranked #2 in USA for
rehab facilities by U.S. News & World Report.
• Mike Feinberg (Resp Care Manager for Kessler Institute) helped us
develop our SCI protocol. Here is what he sent us:
– “There is no conclusive literature that states a non surgically fixed spinal
cord injury patient is safe for the vest.”
• Our conclusion: This is an expert opinion and should not take the
place of a review of the published studies, but we do not use any
device that externally vibrates or shakes these patients (Vest, CPT
thru the bed, etc).
• Story of Ms. M and trauma from falling tree
• VDR-4 as Primary vent for status-asthmaticus pts
in acute, severe respiratory failure
• High energy inspiratory gas takes center of tube
where resistance is the lowest.
• Passive exhalation
• “…all intubated asthmatics are put on the VDR. We
usually start with our traditional settings, and will
increase the Pulsatile flow and reduce the Oscillatory
PEEP to increase the pressure gradient to overcome the
high airway resistance. That awesome “Accelerated
Laminar Flow” takes over and ventilation happens.”
–Denny Gish (Legacy Emanuel Med Ctr)
• Questions?
• We share all of our protocols. Please contact
me at: dalbecke@valleyhealthlink.com
• References: (from case report on slide #4)
1.
2.
Habashi NM. Other approaches to open-lung ventilation: Airway Pressure
Release Ventilation. Crit Care Med. 2005 Mar; 33(3 Suppl): S228-40.
3100B High Frequency Oscillatory Ventilator owner’s manual. CareFusion.
Revision P. Chapter 1 – Warnings; page 2.
• Thank You.