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High Frequency Oscillatory Ventilation

Dr George Findlay Consultant Intensivist University Hospital of Wales Cardiff

Risk factors in ARDS:


Trauma Shock Syndromes (Sepsis,Cardiogenic) Gastric Aspiration Burns Diffuse Pneumonias Near Drowning Metabolic Events (Pancreatitis, Uremia) Drug Overdose Systemic Mediator Release associated Diseases -Transfusion Reaction - Disseminated Intravascular Coagulopathy - Cardiopulmonary Bypass

Absence of Surfactant

Tidal Breathing

Pulmonary Injury Sequence

High Distending Pressures

Airway Stretch / Distortion

Cellular Membrane Disruption

Edema / Hyaline Membrane Formation

Higher FIO2 / Pressures

Barotrauma, PIE, BPD

Pulmonary Injury Sequence:


Endo/Epithelial Damage
Alveolar Cell Injury and/or loss Capillary Congestion Interstitial/Alveolar Edema, Hemorrhage Protein Accummulation Surfactant Deactivation Atelactasis Hyaline Membrane Formation Inflammatory Cell Migration Volutrauma , Stretch forces Increased Protein Leak, Atelectasis

Respiratory Therapy Concepts in ARDS :


Conventional Ventilation : - PEEP, Fi02 - Inverse Ratio - Low Volume Pressure Limited Ventilation - Prone positioning - Perm. Hypercapnia - NO Inhalation - LFPPV + ECCO 2R - Partial Liquid Ventilation Conventional Ventilation + HFJV HFOV

NIH ARDS Network USA


Patients : 850 P/F ratio < 300 (79 % <200 in study)

6 ml/kg 12 ml/kg PIP (avg) 25 33 6 39% PEEP (avg) 6 Mortality 30%

Ventilator < days Organ failure < free days IL-6 blood < levels

Changing Lung Volume in CV:

Paw = Lung Volume !

Optimized Lung Volume : safe window


Overdistension
Edema fluid accumulation Surfactant degradation High oxygen exposure Mechanical disruption
Zone of Overdistention

Injury
Safe Window Volume Zone of Derecruitment and Atelectasis

Derecruitment, Atelectasis Repeated closure / re-expansion Stimulation inflammatory response Inhibition surfactant Local hypoxemia Compensatory overexpansion

Injury
Pressure

Pulmonary Injury Sequence:


Necessity to achieve gas exchange but eliminate tidal breathing
Use of mean airway pressure sufficient enough to maintain a constant intrapulmonary pressure above closing pressure, and eliminate the bi-phasic pressure swing, will alter the development of the pulmonary injury

Meredith K, et al , 1989 - baboons Jackson C, et al, 1990 - ring tail monkeys De Lemos, et al, 1992 - baboons

Pulmonary Injury Sequence:

HFOV:
Produces a more
uniform ventilation pattern Maintains normal architecture of the lungs during ventilation.
CMV lung biopsy 24 h Meredith et al HFOV lung biopsy 24 h

Pulmonary Injury Sequence:

If we cannot prevent the injury sequence , then the target goal is to interrupt the sequence of events ! High Frequency Oscillation does not reverse injury, but will interrupt the progression of injury

Optimized Lung Volume strategy:


1.) Increase Lung Volume above critical opening pressure to the Optimum and keep it there in Inspiration and Expiration ! Benefits: - homogenous gas distribution - reduced regional atelectasis - maximized gas exchange area and pulmonary blood flow - better matching of ventilation/perfusion - reduction of intrapulmonary shunting - reduced Oxygen exposure

HFOV Principle:
CDP Adjust Valve

ET Tube

Oscillator

Patient BIAS Flow

Increase FRC with a super CPAP system

Optimized Lung Volume Strategy:

CT Scan : ARDS pig model 30 kg

Mean Airway pressure 5 cm H2O

Optimized Lung Volume Strategy:

CT Scan : ARDS pig model 30 kg

Mean Airway pressure 25 cm H2O

Optimized Lung Volume Strategy:

CT Scan : ARDS pig model 30 kg

Mean Airway Pressure 40 cm H2O

CT 1

CT 2 CT 3

Paw = CDP
Continuous Distending Pressure

CDP= FRC

Optimized Lung Volume Strategy:


2.) Decrease Tidal Volumes to less or equal then dead space and increase frequency !

Benefits: - no excessive volume swings - reduced regional overinflation and stretching - reduced Volutrauma

GAS EXCHANGE IN HFOV:

1.) Convection (Bulk Flow) Ventilation 2.) Asymetrical Velocity Profile 3.) Taylor Dispersion 4.) Molecular Diffusion 5.) Pendelluft 6.) Cardiogenic Mixing

SUGGESTED READING:

Chang HK. Mechanisms of gas transport during ventilation by HFOV, Brief Review, J Appl Physiol, 1984 Schindler M, et al. Effect of Lung Mechanics on Gas Transport During HFO. Pediatric Pulmonology, 1991

HFOV Principle:
CDP Adjust Valve

ET Tube

Oscillator

Patient BIAS Flow

Decrease TVs to physiological dead space and increase frequency

HFOV Principle:

I + Amplitude Delta P = Tv = Ventilation

+ CDP=FRC= Oxygenation

HFOV = CPAP with a wiggle !

Pressure transmission CMV / HFOV :


Distal

amplitude measurements with alveolar capsules in animals, demonstrate it to be greatly reduced or attenuated as the pressure traverses through the airways. Due to the attenuation of the pressure wave, by the time it reaches the alveolar region, it is reduced down to .1 - 5 cmH2O.

Gerstman et. al

Pressure transmission HFOV :


proximal

trachea alveoli

HFOV Principle: Pressure curves CMV / HFOV

HFOV Principle:
Pressure curves CMV / HFOV

Pressure (Amplitude) Controls CO2 CDP (Paw) Controls O2

HFOV effectively decouples: Oxygenation & Ventilation

Differences between CV and HFOV


Differences Rates CV 0 - 150 HFOV 180- 900

Tidal Volume

4 - 15 ml/kg

0.1 - 5 ml/kg

Alv Press swing

0 - > 50 cmH2O

0.1 - 5 cmH2O

End Exp Vol

Low-normal

High-normal

Gas Flow

Low

High

High Frequency Ventilation Definition:


All rates above 150 breaths per minute (FDA) Twice resting rate and tidal volume equal or less then anatomical dead space (Ackermann) Greater then four times natural breathing frequency (Slutsky)

High Frequency Ventilation in Adults:

HFJV

: High Frequency Jet Ventilation

HFOV : High Frequency Oscillating Ventilation

HV Jet Ventilator in ARDS:


Delivers short pulses of pressurized gas in ET tube
Disadvantages - Simple devices - Need for combination CV/HFJV - Improvement of gas exchange - Need for cannula / modified ET tube - Passive exhalation - Air trapping / Airway stretch - Humidification problems Advantages:

HFOV-HFJV what is different ?


HFOV
Mechanism Frequency

HFJV Jet, Set back Jet 1-10 HZ


(60-600)

Oscillator 3-15 HZ
(180-900)

Exhalation CDP Control

Active Direct setting

Passive Gas trapping by incr. Frequency and set Peep Vaporizer, Nebulizer Humidity Entrainment Modified ETT

Humidity

Standard Humidifier Standard ETT

ET Tube

3100 B HFOV Resume:


Less Oxygen exposure: Stable lung inflation
Recruitment of alveolar space Improved matching V/Q

Reduction of Volutrauma: No conventional breaths needed


Less Volume swings No high peak pressures Active Exhalation Reduces Airtrapping Reduces Airway stretch

HFOV effectively decouples

Oxygenation
and Ventilation

Sufficient Humidification
less risk NTB

31OO B HFOV
Instrument Controls

BIAS Flow ( Continuous Flow )

Continuous Distending Pressure (CDP) Delta Pressure Oscillating Frequency Inspiratory / Expiratory Ratio

HFOV:
( 3100 B settings !)

3100 B

SensorMedics 3100B
Electrically powered, electronically controlled piston-diaphragm oscillator Paw of 3 - 55 cmH2O Pressure Amplitude from 8 130 cmH2O Frequency of 3 - 15 Hz % Inspiratory Time 30% 50% Flow rates from 0 - 70 LPM

31OO B HFOV
Instrument Controls

BIAS Flow ( Continuous Flow )

Continuous Distending Pressure (CDP) Delta Pressure Oscillating Frequency Inspiratory / Expiratory Ratio

Bias Flow Section

Bias Flow 0-60l/min Route: wall Oxygen & Air Blender Flow meter Humidifier Patient Circuit
3100 B

Paw is created by a continuous bias flow of gas past the resistance (inflation) of the balloon on the mean airway pressure control valve.

Oxygenation
The Paw is used to inflate the lung and optimize the alveolar surface area for gas exchange. Paw = Lung Volume

Bias Flow
CDP Control Balloon

Red Line Balloon Control

Balloon Deflation: (valve opening)


-

- main power failure - Map > 60 cm H2O - Map < 5 cm H2O

Oscillator Section

Controls: Frequency (3-15 Hz) Inspiration time (30-50%) pressure (0 - > 130 cm H2O) Start/Stop Button Centering display shows movement of the piston (not position of the piston !) Centering of the piston is connected to I-time (automatically!)

Primary control of CO2 is by the stroke volume produced by the Power Setting.

Alveolar ventilation during CMV is defined as: F x Vt Alveolar Ventilation during HFV is defined as: F x Vt 2 Therefore, changes in volume delivery (as a function of Delta-P, Freq., or % Insp. Time) have the most significant affect on CO2 elimination

Ventilation

Secondary control of PaCO2 is the Frequency set.

Frequency controls the time allowed (distance) for the piston to move. Therefore, the lower the frequency , the greater the volume displaced, and the higher the frequency , the smaller the volume displaced.

Relation Delta Pressure and Oscillating Frequency


Power control adjusts Oscillator movement (forward/backward)
Oscillator movement creates Delta Pressure Delta Pressure controls TV Oscillating Frequency effects TV * Frequency = VCO2 Delta P controls Ventilation, Frequency effects Ventilation Delta P adjustable : > 130 cm H2O Frequency adjustable: 3 - 15 Hertz ( HZ = times per second )

( TV )2

Inspiratory / Expiratory Ratio:


I/E Ratio adjustable with Inspiratory time control
Inspiratory time = Forward movement piston Expiratory time = Backward movement piston Backward movement piston = active exhalation ! Recommended Insp. time = 33% (prevents airtrapping)

30%

+ -70%

Inspiratory time adjustable: 30% - 50%

CO2 removal Block v.s. Sine wave

PCO2

Block

Sine

Block

55 Kg lung lavaged pig Dp 60 CDP 20 FiO2 0.3

Alarm Section ( CDP / MAP )

Alarm Settings:

- maximum CDP (MAP) - minimum CDP (MAP) - source gas low Visual Indicators: - battery low - oscillator overheated - oscillator stopped Alarm Silence Button: - 45 sec. suppression - controls Red line balloon Reset Button:

Pressure Controls CO2 MAP/ CDP Controls O2

Differences 3100A/3100B:
Bias Flow: CDP Adjust: Delta P: Red line balloon valve opening :

3100 A: 0 - 40 l/min 3 - 45 cmH2O >90 cmH2O


max. prox. Amplitude

3100 B: 0 - 60 l/min 7 - 55 cmH2O >130 cmH2O


max. prox. Amplitude

CDP > 50 cmH2O CDP < 20% max.


CDP alarm setting

CDP > 60 cmH2O > 5sec CDP < 5 cmH2O Piston centering connected to I/E Ratio

Piston centering adjustable

Minimum Bodyweight Limit 3100 B:


3100 A Red line balloon valve opening CDP > 50 cm H2O CDP < 20% Max. CDP alarm setting 3100 B CDP > 60 cm H2O > 5 sec. CDP < 5cm H2O

Recommended Patient minimum Bodyweight Limit for the use of the 3100 B is 35 KG !
Upper limits for valve opening in the 3100 B can cause severe complications in infants and pediatric patients below 35 KG bodyweight !

Patient Circuit Calibration

Ventilator Performance Check

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