5-5 1. 4.

(b)

GUIDELINE

SUBJ ECT: High frequency oscillating ventilation (HFOV)

DOCUMENT NUMBER:

5 5. 1. 4 (b)

DATE DEVELOPED:

July 2006

LAST REVISED DATE:

April 2007

PLANNED REVIEW DATE:

April 2010

DISTRIBUTION:
Neonatal Intensive Care Unit
COMMITTEE RESPONSIBLE FOR RATIFICATION AND REVIEW:
NICU Executive Management Committee
NICU Clinical Practice Committee
DEVELOPED BY:
Paul Craven, Staff Specialist, NICU
Disclaimer
It should be noted that this document reflects what is currently regarded as a safe and appropriate approach
to care. However, as in any clinical situation there may be factors that cannot be covered by a single set of
guidelines, this document should be used as a guide, rather than as a complete authorative statement of
procedures to be followed in respect of each individual presentation. It does not replace the need for the
application of clinical judgment to each individual presentation.

SAFE WORK PRACTICES

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Index

Page

Definition
Incidence of HFOV in Australia and New Zealand
Indications for the use of HFOV
Management Principles of HFOV
Methods to Optimise ventilation
Using HFOV in the clinical set up
Switching from Convention to Oscillation on the Stephanie
Warnings of Using Oscillation with the Stephanie
Adjusting the settings of HFOV in the Clinical setting
Recruitment Manoeuvre for HVOF Stephanie ventilator
Managing Specific Conditions with HFOV
Weaning from HFOV
Trouble shooting with HFOV

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Definition
High Frequency Oscillatory Ventilation (HFOV), first described in 1977, has been
described as CPAP with wobbles and was thought to reflect a gentler form of ventilation
1
using supra physiological breathing rates.
Incidence of HFOV use in Australia and New Zealand
Data has been collected since 1996 on the use of HFOV in ANZNN. It was defined as
mechanical ventilation presented at high frequencies (small tidal volumes at frequencies
>4hz).
In 1996, 5.9% of all babies recorded in the ANZNN database had HFOV. In 2001 this had
increased to 12.6%, with the majority of infants being of extreme prematurity (30.9% of
those born at 24 weeks vs. 4.0% born at 32 weeks gestation) and the majority suffering
2, 3
from respiratory distress syndrome.
Indications for the use of HFOV
Elective use in preterm infants
Overall there is no effect on mortality at 28 days or term corrected when compared to
those infants conventionally ventilated. In addition there is no overall difference in chronic
lung disease, although there is a trend to a reduction in the HFOV group, especially when
accounting for the significant heterogeneity. There is no difference in short term
neurological outcome, although for those using a low volume recruitment there appeared
in 2 trials to be an increased risk of severe IVH. The outcome long term is inconsistent.
The problem with looking at these trials is the heterogeneity of them. The 2 largest the
HIFI and the UKOS used different volume strategies. In the HIFI, low volume strategies
were used, with no difference in CLD, mortality, but an increase in IVH. In the UKOS,
volume was increased until oxygen requirements were reduced. This difference negated
the increased incidence of IVH.
Of note is the use of differing ventilatory strategies, oscillator types and user experience.
There is a significant reduction in CLD when analysed by type of ventilator but again this

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introduced heterogeneity. Thus HFOV should be used at the discretion of the on-call
staff specialist. 4
Rescue ventilation in preterm infants with pulmonary dysfunction
There is no difference in mortality or extended ventilation of rescue HFOV vs. conventional
ventilation. There is a statistical reduction in air leak (NNT=6) of using HFOV but no
difference in gross air leak or pulmonary interstitial emphysema. There is an increased risk
of IVH of any grade (NNT=6) and a trend to an increased incidence of severe IVH in those
using HFOV. Using rescue HFOV should be discussed on a case-by-case basis in
5
consultation with the staff specialist.
Rescue ventilation in term infants with severe pulmonary dysfunction
There is no reduction in mortality or failure of ventilatory method requiring cross over. Of
the one trial meeting entry requirements no difference in length of hospital stay, oxygen
6
therapy or chronic lung disease.
Management Principles of HFOV
Advantages
Lung volume recruitment and CO2 removal, with minimal barotrauma.

It is aimed to support the underlying respiratory disease process and the transition
of fetal to neonatal circulation.

Disadvantages
Ma y limit already poor cardiac reserves in the very sick newborn

The relatively constant pleural pressure and minimal lung volume changes may
impede venous return

Ma y worsen gas trapping and air leak

HFOV has been described as CPAP with wobbles and the components of the ventilation
include: 8
Mean Airway Pressure (CPAP)- recruitment and sustained inflation of alveoli. (MAP)
Controls O2
Frequency and Amplitude (wobble) of the oscillating waveform imposed onto the CPAP
Controls CO2
Oxygen
Controls O2
To change O2 and CO 2
The oxygenation can b e increased b y:
Increasing the mean airway pressure (MAP) to recruit alveoli- this has the MOST
profound effect on oxygenation.
Optimum MAP corresponds to an AP chest film with 8-9 ribs showing
Increasing the inspired oxygen concentration

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The oxygenation can b e reduced b y:

Reducing the inspired oxygen concentration
Reducing the mean airway pressure (MAP) to relieve distension on the alveoli
The CO2 can b e reduced b y:
Increasing the amplitude of the oscillating wave
Reducing the frequency of the oscillating wave.
The CO2 can b e increased b y:
Decreasing the amplitude of the oscillating wave
Increasing the frequency of the oscillating wave
Diagrammatic representation of oscillating waveform over PEEP.

.
Methods to optimise ventilation
Bryans Definition
The hallmark of high volume strategy is that the achievement of alveolar expansion
is given higher priority than minimisation of applied pressure, and thus mean airway
pressures early in the treatment of RDS are often higher than in conventional
ventilation. With such a high volume strategy FiO 2 is decreased before pressure and
1
the MAP is only adjusted when FiO 2 requirements do not change.
See diagram over page
Point A - under-inflated with high oxygen requirements
Point B - Well inflated. The lung has opened up. Any further rise in pressure results in
little extra volume recruitment
Point C - over-inflated. CXR determination, 8-10 posterior ribs should be visible
Point D Ventilating on the expiratory limb, achieving maximal inflation with minimal
pressure

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Using HFOV in the clinical setting

Preparation
Infant should be intubated with minimal/no leak around ETT
Arterial access should be achieved both for ABG and MABP monitoring
Tc monitoring is useful and may be used both for O2 and CO2
Continuous saturation monitoring is essential, ideally preductal and both pre and
post ductal if persistent pulmonary hypertension is present
Hypotension should be actively treated. Having 10ml/kg of normal saline ready is
recommended.
Select settings for HFOV
Mean Airway Pressure - This is selected using the PEEP control on the Stephanie.

Start MAP at 1-3cmH2O above mean airway pressure on conventional ventilator.

Increase pressure each 10 minutes by 1cmH2O to achieve good oxygenation
(FiO2<0.3). This is the recruitment strategy. Perform CXR after -1hr to ensure
well-expanded chest at 8-10 posterior ribs. Once FiO2<0.3 decrease pressure
(MAP) until derecruitment occurs (saturations 85% on current settings = Closing
pressure). At this point re-recruit and then drop pressure back to 2cmH2O above the
closing pressure. Ma ximum pressures that have been used are 25cmH 2O.

Frequency strategies - Preterm babies 10-12Hz. A lower frequency can be used to

achieve a drop in CO2 especially in those preterm infants with established PIE (610Hz). In term lung disease a lower frequency can be employed 8-12Hz and
meconium aspiration syndrome (8-10Hz).
Amplitude (Wobb le) Start at twice the mean airway pressure and watch the
CHEST wobble. Watch the TcCO2 or measure blood gases to establish adequate
amplitude. A higher amplitude will lower the CO2

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Switching from Conventional Ventilation to HFOV on the Stephanie

1. Put HFO frequency at 10-12Hz and HFO amplitude to 0
2. Look at Pmean, the PEEP knob becomes the Mean Airway pressure knob in HFO.
The PEEP knob should be set 2-3cmH2O above the Pmean or generally about 1214
3. Turn to CPAP
4. Press HFO button
5. Increase Amplitude HFO until good chest wobble
6. Press Auto Alarm Reset twice, quickly or you will get alarms
7. Fix the chain into the block as per diagram on the side of the machine
8. Adjust the heating in Options to +2.5. If moisture appears in the line turn this back
to +2.0. Always use tube warmers on the circuits
Warnings of using Oscillation with the Stephanie ventilator
1. As the airflow is higher in HFOV the water jar temperature is increased from 02.0/2.5
2. Be aware of the pressure alarms- if the Posc reading (set by the amplitude) on the
screen falls below the Pmax alarm limit which is seen as a green line you will see a
disconnect alarm
3. If the PEEP alarm goes above the low pressure alarm you will get an alarm clash
and you will be asked to change the alarm limits usually by increasing the low Pmax
alarm
4. The PaCO2 can fall extremely fast, do an arterial blood gas 10-15 minutes after
initiating HFOV
Adjusting the settings of HFOV in the clinical setting
Oxygenation - This is achieved by altering the FiO2 or the MAP. An increasing MAP
should be at the discretion of the on call consultant, and X ra y confirmation of chest
expansion should be attended. Over inflation is present if 10+ ribs are present on CXR, if
there is bulging of the lungs at the intercostals spaces or air is present below the apex of
the cardiac shadow. Under inflation is present if there is a high diaphragm and is often
accompanied by areas of atelectasis.
Carbon dioxide CO2 is altered by the amplitude or more rarely by the frequency of the
oscillations.
Recruitment Manoeuvre for HVOF Stephanie Ventilator
Whenever HFOV is disconnected from the patient the lungs will deflate and lose volume.
When the patient is reconnected to HFOV the lung volume will increase again but will not
reach the same volume before the HFOV was disconnected, this is due to hysteresis in the
lung. On SIMV the repeated PIP re-inflate the lung quickly but on HFOV there is no
repeated peak pressure and therefore lung volume is not re-established quickly. To reestablish the lung volume quickly a Recruitment manoeuvre is required. This uses a higher
pressure than the MAP with a long inspiratory time to re-inflate the lung. This manoeuvre
should be done following any disconnection from HFOV (ie after suctioning is completed
and after repositioning)

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This is done in the following way:

1) Set the Inspiratory Hold Time to 5 seconds. (The inspiratory hold time is set from
the options menu).
2) Set the Inspiratory pressure (P Max) 8cm H2O above the PEEP level or above the
MAP)
3) Give a five second inspiration by pressing and holding the Button labelled Insp (top
left button with the outline of a red hand on it) until the ventilator starts back on
HFOV
4) Repeat the 5 second inspiration 3 times in total at 30 second intervals.
5) For further instructions or clarifications see Stephanie Manual.
Managing Specific Conditions with HFOV

(Dr. Chris Wake 14/3/03)

Premature infant with RDS

Set MAP 2cmH2O above MAP when on conventional ventilation
Frequency 10-12Hz, dependent on CO2
Amplitude to control CO2 but need chest wall wobble
Term infant with RDS
Set MAP 2cmH2O above MAP when on conventional ventilation
Frequency 10-12Hz, dependent on CO2
Amplitude to control CO2 but need chest wall wobble and usually higher than for preterm
infants
Air leak syndromes
Set MAP equal to MAP when on conventional ventilation
Frequency 8Hz (larger)-12Hz (smaller), dependent on CO2
Amplitude to control CO2 but need minimal chest wall wobble
Gross Air leak
Set MAP 1cmH2O above MAP when on conventional ventilation
Frequency 12-15Hz, dependent on CO2
Amplitude to control CO2 but need chest wall wobble
Meconium Aspiration Syndrome
Set MAP equal MAP when on conventional ventilation
Frequency 6-10Hz, dependent on CO2
Amplitude to control CO2 but need chest wall wobble
Pulmonary Hypoplasia
These babies frequently fail to have a sustained response, probably secondary to
pulmonary hypertension, and inadequate lung tissue to support gas exchange
Set MAP 2cmH2O above MAP when on conventional ventilation
Frequency 10-12Hz, dependent on CO2
Amplitude to control CO2 but need chest wall wobble
For Congenital Diaphragmatic Hernia the infant is ventilating one lung; therefore HFOV
is introduced at a lower MAP then with other conditions. Do not exceed a PEEP of
15cmH2O

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Weaning off HFOV

1.
2.
3.
4.

Lung volume should be maintained whilst weaning.

Decrease FiO2 to < 0.3
Decrease MAP b y 1cmH20 at a rate determined by the consultant
At a MAP of 8cmH2O either:
Extubate to CPAP or
Change to SIMV/Assist Control

Troubleshooting with HFOV

Hypoxia
Displaced Tube
Obstructed Tube
Pneumothorax
Equipment failure
Ineffective MAP may require increasing, or if over distended may need decreasing.
Ensure delivering correct FiO2
High CO2
Ma y occur as a result of:

Displaced Tube
Obstructed Tube
Pneumothorax
Equipment failure
Increase Amplitude; make sure the chest wall is moving
Reduce oscillator frequency; especially in term infants
Low CO2
Chest wall movement excessive- reduce amplitude
Increase frequency
Change to conventional ventilation
Hypotension/Acidosis
Over distended with venous return obstruction
Reduce MAP
Check for pneumothorax
Consider the need for volume expansion and inotropes

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References
1. Bryan AC: The oscillations of high-frequency oscillation. Am J Respir Crit Care Med
2001; 163:816817
2. Donoghue D. The Australian and New Zealand Neonatal Network
3. High Frequency Oscillatory Ventilation workshop- From Art to Science, 2004
4. DJ Henderson-Smart, T Bhuta, F Cools, M Offringa. Elective high frequency oscillatory
ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm
infants. Cochrane Database of Systematic Reviews 2007 Issue 1
5. T Bhuta and DJ Henderson-Smart. Rescue high frequency oscillatory ventilation versus
conventional ventilation for pulmonary dysfunction in preterm infants. Cochrane
Database of Systematic Reviews 2007 Issue 1
6. T Bhuta, RH Clark, DJ Henderson-Smart. Rescue high frequency oscillatory ventilation
vs conventional ventilation for infants with severe pulmonary dysfunction born at or
near term. Cochrane Database of Systematic Reviews 2007 Issue 1
7. Guidelines for the use of High Frequency Oscillatory Ventilation. Princess Margaret
and King Edward Memorial Hospital Neonatal Clinical Care Unit.
8. High frequency Oscillatory Ventilation. Department of Neonatal Medicine Protocol
Book. Royal Prince Alfred Hospital.

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