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David Albecker, BS, RRT-NPS, RPFT

David Albecker, BS, RRT-NPS, RPFT. VDR-4 – A Case Report With additional clinical-use points. Conflict of Interest Statement.

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David Albecker, BS, RRT-NPS, RPFT

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  1. David Albecker, BS, RRT-NPS, RPFT VDR-4 – A Case Report With additional clinical-use points

  2. Conflict of Interest Statement 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

  3. High Frequency Percussive Ventilation as Rescue Therapy for a Patient with Acute Respiratory Distress Syndrome and Septic Shock following Bilateral Pneumonia (April, 2012) • 58 year old female w/ Hx of COPD and long-term tobacco abuse • Bilateral CAP • Septic shock → ARDS • BP 72/53 • Febrile • pH ≈ 7.0 • Thick, yellow pulm secretions • CXR – bilateral infiltrates all 4 lung quadrants • Static Compliance ≈ 27ml/cm H2O • Corrected MV = 16.2 L/min • NSTEMI during critical illness complicated the case • Arterial and Triple-Lumen central venous catheters inserted • 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

  4. The Transition to HFPV • Refractory hypoxemia that was not improving with conventional VC A/C • Copious thick, yellow pulmonary secretions as noted by the intubating physician • In our opinion, starting the VDR-4 in ARDS is better done sooner than later • We decided against APRV because the heavy sedation meant she would not breathe spontaneously in the Thigh phase & therefore she could not contribute to CO2 clearance - importantfor success w/ APRV 1 • We decided against the 3100B because the active exhalation can cause gas trapping in severe COPD pts 2

  5. Transition From APRV to HFPV in Adult ICU-How we do it- • APRV Settings: • The “Habashi way” • PHIGH = ? • PLow= 0 • THigh ≈ 4-6 sec • TLow ≈ 0.8 sec • FiO2 = ? • Observe MAP • HFPV Settings: • PIP ≈ PHIGH from APRV • PEEP ≈ 10-15 • Consider MAP & TLow exp flow inflection point • I-Time = 2 sec • E-Time = 2 sec • Default rate = 15 • Percussive rate=600/min • FiO2 = FiO2 on APRV

  6. Transition From VC A/C to HFPV in Adult ICU-How we do it- • VC A/C Settings: • VT = 6ml/kg IBW • Measured Pplat = ? • Rate = ? • PEEP = ? • FiO2 = ? • Observe MAP • HFPV Settings: • PIP ≈ Pplat from VC A/C • PEEP = PEEP from VC A/C • I-Time = 2 sec • E-Time = 2 sec • Default rate = 15/min • Percussive rate=600/min • FiO2 = FiO2 on VC A/C • Consider MAP on VC A/C

  7. Transition from 3100B to VDR-4 in adult ICU-How we do it- • Example: 3100B • MAP = 34 cm H2O • Amplitude = 90 cm H2O • FiO2 = ? • Hz = 3, 4, 5, or 6 • % I-time = 33% • Consider: tops of Amplitude pressure spikes ≈ 79 cm H2O • Bottom of Amp waveform could be -10 cm H2O! • HFPV settings: • Consider MAP to set PEEP, not bottom of 3100B Amp waveform • Setting PIP - Monitron PIP ≈ 3100B top of Amplitude waveform • AIP on Multimeter (sustained PIP) will be lower & clinically usable • Match FiO2 • I-time= E-time = 2 sec • Percussive rate = 600

  8. ETCO2 - Yes w/ VDR-4 Dedicated Expiratory Half-Cycle on VDR-4 allows ETCO2 measurement

  9. MDI/Aerosol Bronchodilators • Work well w/ VDR-4 • Delivered tidal volume allows MDI/aerosol use • Similar to VC or PC w/ conventional vent • Time inhalation w/ inspiratory phase • Place MDI adaptor between Phasitron and ETT/trach • Aerosol med through Aerogen neb or regular neb • We place between inspiratory limb of circuit and green inspiratory port of Phasitron, can also be placed between ETT/Trach and Phasitron

  10. Ventilation and ETT Cuff Leak • 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 • “Gives lung time to get out of it’s own way” • Decrease percussive rate from 600 to 450 • (for COPD pt) Increase sinusoidal E-time allowing for better exhalation

  11. Many ways to improve oxygenation w/ VDR-4 • ↑ 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

  12. Humidity w/ the VDR-4You must pay close attention to humidityPassover + Aeroneb Solo – similar to disposable circuit + Passover Phasitron w/ Aerogen neb Complete circuit w/2 humidifiers

  13. VDR-4 w/ Flolan Delivery- How we do it - Pumps w/ Syringes Connection to VDR-4: stopcock extension sets from syringes attach to 3-way stopcock @ Aeroneb Solo which runs in continuous mode

  14. INOmax w/ the VDR-4Slides 16, 17 & 18 come from Brent Kenney’s presentation

  15. INOmax w/ the VDR-4We 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

  16. INOmax w/ the VDR-4 Blended gas to INOblender, then flow out to adaptor @ Phasitron. Sample line to sample line inlet port. INO concentration measured in standard way but adjustments made @ INOblender

  17. A closer look at the set up w/ the INOmax

  18. Guidelines for resp care in severe hypoxemic respiratory failure/ARDS Pathway that we follow for the difficult-to-oxygenate pt By the time we get to ECMO, we are almost always on the VDR-4 In general, we use low resting settings that keep lungs open We have a partnership w/ VCU for ECMO pts in adult ICU

  19. Introducing HFPV w/ the VDR-4 to an ICU with no previous experience- How we did it - • Experienced physician champion is a must (for us it was Dr Barillo) • We developed a HFPV protocol for adult ICU • After I was trained by Dr Barillo, I did short, introductory (1 on 1)inservices for as many ICU nurses as possible (both shifts) covering the VDR-4 • When done, 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

  20. Let’s not forget the IPV – after all, it has a Phasitron too. Our protocol algorithm:

  21. In ouropinion: where the IPV really shines • We have a protocol for the respiratory care of the spinal cord injured (SCI) pt • After the initial acute phase, how do you maintain lung clearance and expansion long-term? • IPV + Cough Assist = Perfect! Why IPV? • Next slide…

  22. What does the expert say? • 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 wrote: • “There is no conclusive literature that states a non surgically fixed spinal cord injury patient is safe for the vest.” • 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).

  23. Conclusion • Questions? • We share all of our protocols. Please contact me at: dalbecke@valleyhealthlink.com • References: (from case report on slide #4) • 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, page 2. • Thank You.

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