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Dr Abid Ali Rizvi

Lost in a Maze

User manual is superficial, with poor translation from German. Nothing useful is available online about this machine. Experts outside Germany are not very familiar. Lack of interest in the end users.

HFO: Whats different in Sophie ?


Amplitude and Posc Vo and MVo of HFO HF I:E Ratio Optimum Frequency Pmax and Insp Sigh breaths Flow limit The HFO seal

Amplitude, DP, & Posc: Notice the units in which the parameters are displayed.

Amplitude (DP) cmH2O

FYI: 1mbar = 1.012 cmH2O

Pressure of Oscillation (Posc) in cmH2O


Amplitude (%): Sophie expresses the depth of oscillations as a percentage swing (peak to trough) around MAP. Its range is : 0-100% . Posc is the actual pressure gradient (P in cmH2O), generated by the piston to create the desired percentage swings around the MAP.

Diagram
Peak PRESSURE

MAP (Paw)
Trough Pressure

In the previous slide


MAP is 13 cmH2O, Amplitude is 12%, & Posc is 21 cmH2O Requested Swing around MAP = 3.12 cmH2O [12% of 13 = 1.56] + [12% of 13 = 1.56] = 3.12 cmH2O
Above MAP

Below MAP

But actual oscillation generated are:


Peak = 24 cmH2O & Trough = 3 cmH2O

P of [24 3] = 21 is required in this case to actually oscillate the MAP of 13 by 3.12 cmH2O in each cycle.

Factors influencing the Posc [DP] magnitude (for the


same set Amplitude):

Impedance [Z]

Impedance is the total opposition that a circuit (tubing, ET and airways) has against a passing oscillatory current (of air flow).

[Z]

Resistance [R] + Elastance [E] + Inertance [I]

A high impedance circuit will result in high Posc [DP], but low gas flow & tidal volume.

Factors influencing the Posc [DP] magnitude (for the


same set Amplitude):

Compliance [C]

Stiffer the lungs, the DP generated will be high; Transmission of the DP to alveoli is when [C] is [C] of chest wall or abdomen also contributes in DP size. Level of water in the humidifier bottle inversely alters the compliance the ventilator tubing (circuit). Over-distended lungs have poor compliance.

Factors influencing the Posc [DP] magnitude (for the


same set Amplitude %):

Frequency [F]

Impedance of the ET & airways es at higher [F].

DP size therefore increases at higher frequencies.


Transmission of DP from ET to alveoli is also ed with increasing frequencies. This damping of DP (with increasing Frequency)

across the ET occurs mainly with I:E ratio of 1:2 rather than 1:1.

Factors influencing the Posc [DP] magnitude (for the same set Amplitude): MAP [Paw]

When MAP is reduced, DP will also decrease to keep the percentage swing (Amplitude) same. Over-distended lungs (due to high Paw) have lower compliance (even if healthy), therefore, they will generate high DP

When Posc (P) is found too large especially on a low MAP.


risk of de-recruitment &/or gas trapping during expiratory phase especially if the trough pressure is reaching sub-zero values. Weaker parts of distal most bronchioles will collapse and create choke points, resulting in incomplete alveolar emptying. This effect is exaggerated when airway resistance is high in combination with surfactant deficiency (e.g. Meconium Aspiration).

P Trough reaching sub-zero values

Setting the alarm limits for Posc:


30% above and below the current value is recommended so that we can get a clue if ET resistance or lung compliance has changed significantly.

Vo: [Tidal Volume of Oscillation] in mL


By dialing an amplitude, the machine generates Posc (DP) which in turn yields a tidal volume for each oscillatory cycle. Vo is the basis of bulk convection which is the major component of the 6 gas exchange mechanisms in HFO ventilation.

Direct ventilation of close by alveoli

Turbulence

Convection

Radial Mixing Pendelluft

Asymmetric velocity profiles in inspiration and expiration

Convection & Diffusion

Cardiogenic oscillations

Diffusion

Diffusion

Collateral ventilation

Mixing by asymmetric velocity profiles is also convection (flow) dependent.

Expiratory flow

Inspiratory flow

Vo: [Tidal Volume of Oscillation] in mL


Recommended Vo for effective HFO ventilation is 2-2.5 ml/kg, which is roughly the anatomical dead space volume in Term Neonates. If Vo is < 50-75% of the anatomical dead space, there is generally a deterioration of gas transport efficiency, even if the HFO frequency is proportionately increased to maintain the minute volume.

1) Patient is 1.5 kg, so Tidal Volume per cycle is 71.5 = 4.7 mL/kg. 2) This baby is not getting any benefit of HFOV, in fact he is on super-IMV. 3) This is the advantage of keeping an eye on Vos.

Tidal Volume and Lung Injury go Hand in Glove.

ET size decides the way Frequency changes the Vo (tidal vol. in mL)
MAP 10, DP 50, Insp 33%

Vo (tidal vol. in mL)

COMPLIANCE NORMAL
OVER COMPLIANT LUNG

3.5 ET

3.0 ET

2.5 ET

STIFF LUNG

Frequency

ET 2.5

NORMAL LUNG

Minute volume of Oscillation (MVo) in L/min


It is the total amount of air exhaled back into the HFO in one minute. Measured directly using the flow sensor at the ET end of the circuit. [Vosc] x [Frequency] This parameter is used to calculate:
DCO2 (Gas Exchange Coefficient). Pressure cost of ventilation.

What is DCO2 in HFO ?


A mathematical model which predicts the chances of normal pCO2 DCO2 per Kg of 60-80 pCO2 < 6.7 in ~80% cases. DCO2 = [Tidal Vol]2 X Frequency = [Minute Vol]2 Frequency

Minute volume of Oscillation (MVo)


3.0 2.5
Sophie
ET 2.5, MAP 15, DP 30, F 6-15 Hz

SLE 5000

3100A

2.0 1.5 1.0 0.5


6 7 8 9 10 11

MVo in L/min

Infrasonic

Babylog8000

MVo in HFOV is independent of frequency in Sophie, Sensormedics 3100A and SLE 5000

FREQUENCY IN HERTZ Frequency

12

13

14

15

It pays to pay attention on I:E Ratio


1. Machines default setting is at 40% which may increase the risk of barotrauma, cardiac compression and gas trapping [Traditional teaching]
Inspiratory share (HF I-E ratio) should be kept at 33% (1:2).

HF I:E %: Set Versus Delivered


This is NOT the HFO I:E Ratio

HFO I:E Ratio [ %], keep it 33%

Inspiratory time: 33% [1:2 ratio]


It is an extrapolation of the I:E Ratio of 1:2 of the conventional ventilation. With I:E Ratio of 1:2, delivered intra-alveolar pressure is significantly lower than the set MAP. Protection from barotrauma, but at the expense of optimum alveolar recruitment. There is no difference in the incidence of gas trapping with either 1:2 or 1:1 Ratio.

Inspiratory time: 50%[I:E Ratio 1:1]


Delivers MAP to the alveoli without damping. That means intra-alveolar pressure is actually same as the displayed MAP. Good for opening the lungs but barotrauma risk. Although Vo (tidal volume) delivered is higher at I:E Ratio of 1:1, gas trapping does not occur. Resulting higher MAP in distal lung units splints them open more efficiently. This lowers the airway resistance in expiration phase, allowing complete emptying of the alveoli.

To Avoid Air Leaks


Be very careful if using high MAP &/or huge DP in neonates, when HFO is operating at/close to I:E Ratio of 1:1
This combination is seen in: SLE 5000 ALWAYS. Sophie OFTEN. SensorMedics NEVER.

Drger, SLE 5000 and Sophie support I:E Ratio of 1:1 (Insp Time: 50%)
Effect of I/E ratio on mean alveolar pressure during high-frequency oscillatory ventilation. J. J. Pillow Journal of Applied Physiology July 1999. An in vitro assessment of gas trapping during high frequency oscillation. Jaana A Leipl, Anne Greenough et al 2005 Physiol. Meas. 26 329 Matching Ventilatory Support Strategies to Respiratory Pathophysiology. Anne Greenough, Steven M. Donn. Clin Perinatol 34 (2007) Elsevier

Pa = Mean alveolar pressure Pao = Mean pressure at airway opening (ET)

Pdiff = (Pa-Pao)
INSPIRATORY TIME %

Analyze This

Higher frequencies (13-15Hz) Adequate time may not be available for the piston to complete the forward stroke displacement. The piston then will not be completing its full deflection in the inspiration for generating the required peak pressure.

Short Insp. Time 33% (I:E ratio 1:2)

Large Amplitude Demands

How do these machines tackle the problem of insufficient forward stroke time
Sensormedics 3100A: Insp. time % is never compromised by the machine. Machine may lower the MAP &/or the P delivered. Stephan Sophie: Will not compromise on MAP and Amplitude. Machine increases the insp time % automatically to deliver the P. SLE 5000: Has a fixed I:E Ratio of 1:1,[it has no dial for I:E Ratio]

What happened here?

Blue is square pressure wave of Sensormedics 3100A

Red is the quasi-sine wave in Sophie Green is a pure sine wave, for comparison.
Active expiration has still not started.

Forward flow of gas can therefore occur in this phase.

Fidelity of I:E ratio, set vs. measured


Insp time% we dial in Sophie, is the setting up the electronic timers signal duration for the forward piston displacement. It does not reflect the resultant duration of the forward air flow, which is measured in real-time by the pneumotachograph. If the impedance of the airways/ET is low, the actual forward air flow may not cease as soon as the piston stops the inspiratory stroke.

Pmax and Insp


Press Insp Hold Button for inline bagging (without disconnection) Breath will be given at the set Pmax, and for the duration of the Insp ( its Ti in sec). Its like a manual conventional breath for boosting alveolar recruitment. To be effective, the Ti should be around 1 sec and Pmax should be close to the Posc peak.

Pmax and Insp

Adding regular sigh breaths to HFO


Set HFO from the IMV menu instead of CPAP menu. Useful in lungs with major atelectasis. Contraindicated in presence of established /impending barotrauma. This mode is used for few hrs, once the atelectasis is resolved, sigh breaths do not offer any additional advantage. MAP is displayed as PEEP when adding sigh breaths in HFO. Rate of sigh breaths is generally 1-5 per min; and Ti is kept close to 1 sec.

photo

HFO Seal
Nurses plug it when HFO is started. It seals (disables) a mechanical safety valve through which baby can breath room air, if the ventilator fails completely. This valve will also open (and disturb the HFOV of baby) when ever a negative pressure of minus 6 is generated in ET by the spontaneous breaths or by deep troughs in delta P (high amplitude setting).

Flow limit
Recommended setting is at 2 liters. If the difference between inspiratory and expiratory flow rate is more than 2L/min, then it machine will consider it as ET disconnection or dislodgement and give an alarm. If the ET is very leaky, than set this parameter at a higher limit, to prevent false alarm.

Importance of heat & humidification in HFO


Since the minute volume in oscillator is up to 10 times the conventional ventilation, the heat and humidity loss from the upper airway can be massive if not taken care of. Gas temp should be 36.5-37.5O C. Humidity of the inhaled gases:
Ideal 100% Minimum 70%