Clinical Simulationsfor the
Life Pulse HFJV
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Clinical Simulationsfor the
Life Pulse HFJV
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Patient #1• 24 weeks gestation
• 600 gms
• RDS and early chronic changes post-surfactant
• Intubated, on Jet ventilator
What are your concerns?
• Surfactant has failed• Baby has evolving chronic lung injury• Avoid further injury from CV
What will you be watching (respiratory)?
• ABGs• X-rays for reversal of pulmonary pathogenesis
What general HFJV strategy would you consider?
• Optimize PEEP, minimize CMV support, and avoid gas trapping
• 7.16 pH• 66 PaCO2
• 49 PaO2
• 72 SaO2
2 hours of life
•28 PIP• 5 PEEP • 2 CV IMV•420 bpm•1.8 Servo•26 FiO2
• Raise HFJV Rate to 480 and raise FiO2 to 36%
• Raise PEEP to 7 and increase HFJV PIP to 30
• Raise CV rate to 5 and raise FiO2 to 36%
• Raise HFJV Rate to 480 and raise FiO2 to 36%
• Raise PEEP to 7 and increase HFJV PIP to 30
• Raise CV rate to 5 and raise FiO2 to 36%
2 hours of life
•28 PIP• 5 PEEP • 2 CV IMV•420 bpm•1.8 Servo•26 FiO2
• 7.16 pH• 66 PaCO2
• 49 PaO2
• 72 SaO2
‣ Raising HFJV rate would promote gas trapping
‣ Raising FiO2 may not be necessary if PEEP is optimized
‣ Raising PEEP stabilizes alveoli
‣ Raising HFJV PIP maintains ΔP to maintain VT
‣ CV breaths tend to aggravate existing lung injury, create new injury, and increase risk of pulmonary airleaks.
‣ Raising FiO2 may not be necessary if PEEP is optimized
• Lower HFJV Rate to 360 and CV to CPAP
• D/C HFJV, apply low rate, low pressure CV, and increase FiO2 to 50%
• Wean PEEP to 6 and and raise FiO2 to 50%
4 hours of life
• 7.27 pH• 53 PaCO2
• 58 PaO2
• 85 SaO2
•32 PIP• 7 PEEP • 2 CV IMV•420 bpm•2.2 Servo•26 FiO2
4 hours of life
•32 PIP• 7 PEEP • 2 CV IMV•420 bpm•2.2 Servo•26 FiO2
• Lower HFJV Rate to 360 and CV to CPAP
• D/C HFJV, apply low rate, low pressure CV, and increase FiO2 to 50%
• Wean PEEP to 6 and and raise FiO2 to 50%
• 7.27 pH• 53 PaCO2
• 58 PaO2
• 85 SaO2
‣ Lowering HFJV rate may reduce mild gas trapping and may stimulate baby’s spontaneous respirations
‣ Optimal PEEP eliminates the need for background IMV
‣ Returning to CV would put the baby at risk of recurring injury
‣ Increasing FiO2 may stunt alveolar growth and risks oxygen-related injury
‣ PEEP is a better way to oxygenate than is FiO2
‣ Increasing FiO2 may stunt alveolar growth and risks oxygen-related injury
Patient #2• 32 weeks
• 1240 gms
• Prolonged Rupture of Membranes
• Condition digressing
What forms of ventilation would you consider?• NCPAP, CMV, HFJV
What are your concerns?
• Infection• Cardiac function, BP, nutrition, secretions, gentle ventilation
What will you be watching (respiratory)?
• Vital signs• ABGs
Starting CV Settings
• 27 PIP• 5 PEEP• 32 CV Rate• 68 FiO2
• 0.4 TI
30 Minutes of Life
• 7.09 pH• 72 PaCO2
• 57 PaO2
• 76 SaO2
• 27 PIP• 5 PEEP• 32 CV Rate• 90 FiO2
• 0.4 TI
What now?
• 100% FiO2
• TcPCO2 Climbing• HR Dropping• PNEUMO!• CT Placed
• Raise CV rate to 60, lower I-time to .25
• Start HFOV
• Start HFJV
1 Hour of Life
• 100% FiO2
• TcPCO2 Climbing• HR Dropping• PNEUMO!• CT Placed
• Raise CV rate to 60, lower I-time to .25
• Start HFOV
• Start HFJV
1 Hour of Life
‣ Patient has failed CV and experienced VILI
‣ HFOV requires equal or greater MAP
‣ Restricted to an I:E Ratio of 1:2
‣ Minimal advantage over CV for pneumothoraces
‣ HFJV has rich tradition of resolving airleaks
‣ HFJV is effective at lower PIPs and MAPs
‣ Can provide an I:E Ratio up to a 1:12
Starting HFJV Settings - 1 Hour of Life
HFJV
• 27 PIP• 7 PEEP• 300 Rate• 0.02 TI
• 100 FiO2
• 27 PIP• 5 PEEP• 32 CV Rate• 100 FiO2
• 0.4 TI
0 7 CPAP0
0
HFJV is indicated fortreating pulmonary airleaks.
CV
3 Hours of Life
• 27 PIP• 9 PEEP• 300 Rate• CPAP CV• 0.02 TI
• 52 FiO2
• 7.49 pH• 32 PaCO2
• 87 PaO2
• 97 SaO2
• Raise CV rate to 5, wean HFJV PIP to 24
• Wean HFJV PIP to 25 and FiO2 to 45%
• Wean HFJV PIP to 22, FiO2 to 45%
3 Hours of Life
• Raise CV rate to 5, wean HFJV PIP to 24
• Wean HFJV PIP to 25 and FiO2 to 45%
• Wean HFJV PIP to 22, FiO2 to 45%
• 27 PIP• 9 PEEP• 300 Rate• CPAP CV• 0.02 TI
• 52 FiO2
• 7.49 pH• 32 PaCO2
• 87 PaO2
• 97 SaO2
‣ Raising CV rate risks Ptx reaccumulation
‣ Not necessary to raise CV rate when weaning patient from HFJV
‣ Moderate drops in HFJV PIP are appropriate for raising PaCO2 and lowering pH
‣ Wean FiO2 whenever possible
‣ Weaning HFJV PIP too aggressively is ill advised
‣ Small changes in ΔP can have a significant impact on PaCO2
26 Hours of Life• 0 PIP•3.5 PEEP• 0 CV Rate• 21 FiO2
• 0 TI
Why these settings?
EXTUBATED!
Patient #3• 40 weeks
• Meconium Aspiration Syndrome
• Paralyzed
• Receiving CMV
What other forms of ventilation would you consider?
What are your concerns?
What will you be watching (respiratory)?
• Gas trapping• Evacuation of meconium• PPHN, CMV compromising hemodynamics • Avoiding pulmonary airleaks
• HFJV, HFOV
• Meconium in secretions when Sx• Ptx• Gas trapping• ABGs
HFJV selected due to concerns about secretions, gas trapping, and
hemodynamics
• 7.07 pH• 75 PaCO2
• 42 PaO2
• 57 SaO2
•26 PIP•5 PEEP •50 Rate•80 FiO2
Pre-HFJV Settings on CMV
• PIP 35, HF Rate 420, PEEP 5, FiO2 80, CV Rate 5
• PIP 22, HF Rate 360, PEEP 6, FiO2 80, CV CPAP
• PIP 28, HF Rate 240, PEEP 8, FiO2 80, CV CPAP
•26 PIP•5 PEEP •50 Rate•80 FiO2
• PIP 35, HF Rate 420, PEEP 5, FiO2 80, CV Rate 5
• PIP 22, HF Rate 360, PEEP 6, FiO2 80, CV CPAP
• PIP 28, HF Rate 240, PEEP 8, FiO2 80, CV CPAP
• 7.07 pH• 75 PaCO2
• 42 PaO2
• 57 SaO2
Pre-HFJV Settings on CMV
• PIP 35, HF Rate 420, PEEP 5, FiO2 80, CV Rate 5
PromotesGas Trapping
Risk ofPneumothorax
• PIP 22, HF Rate 360, PEEP 6, FiO2 80, CV CPAP
• PIP 28, HF Rate 240, PEEP 8, FiO2 80, CV CPAP
After 2 hours on HFJV
• 7.52 pH• 32 PaCO2
• 72 PaO2
• 96 SaO2
• 28 PIP• 8 PEEP• 240 Rate • CV CPAP• 50 FiO2
• 2.9 Servo
• Lower PIP to 20 and lower PEEP to 6
• Lower PIP to 25 and repeat blood gas in 30 minutes
• Extubate to NCPAP of 6 cm H2O
After 2 hours on HFJV
• 28 PIP• 8 PEEP• 240 Rate • CV CPAP• 50 FiO2
• 2.9 Servo
• Lower PIP to 20 and lower PEEP to 6
• Lower PIP to 25 and repeat blood gas in 30 minutes
• Extubate to NCPAP of 6 cm H2O
• 7.52 pH• 32 PaCO2
• 72 PaO2
• 96 SaO2
‣ Lowering HFJV PIP in large increments is illadvised
‣ Too early to lower PEEP with FiO2 still at .50
‣ PEEP is the most stable, static, and safest pressure we apply
‣ Lower HFJV PIP in small increments
‣ Repeating blood gas rules our serendipity and reveals impact of pressure change
‣ Too early to extubate
‣ Patient needs more time and is on very gentle lung protective ventilation
After 24 hours on HFJV
• 7.41 pH• 38 PaCO2
• 84 PaO2
• 96 PaO2
• 17 PIP• 6 PEEP• 8 MAP• 240 Rate • CV CPAP• 24 FiO2
• 3.5 Servo
• D/C HFJV: CV Rate 10, PIP 17, PEEP 6
• Lower HF PIP to 13 and repeat ABG in 30 minutes
• Extubate to NCPAP of 8
• Extubate to NCPAP of 5
After 24 hours on HFJV
• 17 PIP• 6 PEEP• 8 MAP• 240 Rate • CV CPAP• 24 FiO2
• 3.5 Servo
• D/C HFJV: CV Rate 10, PIP 17, PEEP 6
• Lower HF PIP to 13 and repeat ABG in 30 minutes
• Extubate to NCPAP of 8
• Extubate to NCPAP of 5
• 7.41 pH• 38 PaCO2
• 84 PaO2
• 96 PaO2
‣ Placing baby on more invasive form of ventilation, with large VT and relatively long TI, risks complications
‣ HFJV is already on very low “extubatable” settings (ΔP is only 9 cm H2O).
‣ Time to get the tube out!
‣ Set NCPAP level to match last MAP value
‣ Supports adequate lung volume and oxygenation
‣ NCPAP same as PEEP may be too low
‣ Set NCPAP level to match last MAP value
Congratulations!You have progressed successfully
through these 3 challenging clinical simulations.
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