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SLE5000

SLE5000. HFOV Presented by SAYU ABRAHAM. High Frequency Ventilation. Defined by FDA as a ventilator that delivers more than 150 breaths/min. Delivers a small tidal volume, usually less than or equal to anatomical dead space volume.

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SLE5000

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  1. SLE5000 HFOV Presented by SAYU ABRAHAM

  2. High Frequency Ventilation • Defined by FDA as a ventilator that delivers more than 150 breaths/min. • Delivers a small tidal volume, usually less than or equal to anatomical dead space volume. • While HFV’s are frequently described by their delivery method, they are usually classified by their exhalation mechanism (active or passive).

  3. Differences between HFOV and CMV CMV HFOV Rates 0 - 150 180 - 900 Tidal Volume 4 - 20 ml/kg 0.1 - 5 ml/kg Alv Press 0 - > 50 cmH2O 0.1 - 5 cmH2O End Exp Vol Low Normalized

  4. High Frequency Ventilation • Types of HFV’s Approved for use in both Neonates and Pediatrics • SLE5000 HFOV • SensorMedics 3100A HFOV • Bird Volumetric Diffusive HFPPV • Types of HFV’s Approved for use in Neonates Only • Bunnell Life Pulse HFJV • Infrasonics Infant Star (discontinued) HFFI

  5. SLE5000 • Electrically powered, electronically controlled • Conventional and HFOV ventilator • Paw of 3 - 35 mbar • Delta P from 4 – 180 mbar • Frequency of 3 - 20 Hz • I:E Ratio 1:1 • Active exhalation

  6. Insp. Line Resistor (Trigger sensibility) “HFOV”:SLE 2000 Bias flow 5l/min Peep adjustment Rotating jet Exp. Valve Block

  7. Indications of HFOVNeonatalRDS/HMDAir leak syndromesMASPPHNCDH

  8. Ventilator Induced Lung Injury • Barotrauma • Volutrauma • Stretch Injury • Biochemical Injury

  9. Pulmonary Injury Sequence of the neonatal patient: Absence of Surfactant Atelactasis Tidal Breathing High Distending Pressures Airway Stretch / Distortion Cellular Membrane Disruption Edema / Hyaline Membrane Formation Higher FIO2 , Volumes, Pressures Volutrauma, Barotrauma, Biotrauma PIE, BPD

  10. 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.

  11. Ventilator Induced Lung Injury Premature baboon model Coalson J. Univ Texas San Antonio

  12. Ventilator Induced Lung Injury Premature baboon model Coalson J. Univ Texas San Antonio

  13. Pulmonary Injury Sequence • There are two injury zones during mechanical ventilation • Low Lung Volume Ventilation tears adhesive surfaces • High Lung Volume Ventilation over-distends, resulting in “Volutrauma” • The difficulty is finding the “Sweet Spot” Froese AB, Crit Care Med 1997; 25:906

  14. Ventilator Induced Lung Injury • HFOV with Surfactant as Compared to CMV with Surfactant in the Premature Primate • HFOV resulted in • Less Radiographic Injury • Less Oxygenation Injury • Less Alveolar Proteinaceous Debris • Jackson C AJRCCM 1994; 150:534

  15. HFOV

  16. Theory of Operation • Oxygenation is primarily controlled by the Mean Airway Pressure (Paw) and the FiO2 • Ventilation is primarily determined by the stroke volume (Delta-P) and the frequency of the ventilator.

  17. HFOV effectively decouples:Oxygenation & Ventilation

  18. HFOV Principle:Pressure curves CMV / HFOV Injury Injury

  19. Principles of the SLE5000 HFOV “Super-CPAP” system to maintain lung volume

  20. Optimized Lung Volume Strategy: 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

  21. Optimized Lung Volume Strategy: Decrease Tidal Volumes to less or equal to dead space and increase frequency. Benefits: - enhanced gas exchange due to combined gas transport mechanisms - no excessive volume swings - reduced regional over-inflation and stretching - reduced Volutrauma

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

  23. CT 2 CT 1 CT 3 • CDP = • Lung Volume Paw = CDP Continuous Distending Pressure

  24. “Open up the lung up and keep it open!” Burkhard Lachmann, 1992

  25. Primary control of CO2 is by the stroke volume produced by the Delta P Setting.

  26. Regulation of stroke volume • The stroke volume will increase if • The amplitude increases (higher delta P) Stroke volume

  27. Secondary control of PaCO2 is the stroke volume produced by the set Frequency.

  28. Regulation of stroke volume • The stroke volume will increase if • The amplitude increases (higher delta P) • The frequency decreases (longer cycle time) Stroke volume

  29. HFOV Principle: I + + + + + Amplitude Delta P = Tv = Ventilation CDP=FRC= Oxygenation E - - - - - HFOV =CPAP with awiggle!

  30. Pressure transmission Gerstmann D.

  31. I + + + Amlitude Delta P = TV = Ventilation + + + CDP / MAP = Lungvolume = Oxygenation + + + + _ _ _ _ _ _ _ _ _ E Airway Pressure Transmission HFOV : Pressure ET Tube Trachea Alveolus Transmission

  32. HFOV Mechanisms of Gas Transport

  33. Mechanisms of HFOV Gas Exchange • There are six mechanisms of gas exchange during HFOV • Convective Ventilation • Asymmetrical Velocity Profiles • Taylor Dispersion • Pendeluft • Molecular Diffusion • Cardiogenic Mixing

  34. Practical preparation • Avoid leak around the E.T tube • Tc PO2,CO2,Pulse oxymeter and invasive blood pressure monitoring • Baseline CXR • Optimize blood pressure and perfusion(volume replacement and inotropes) • Muscle relaxant/sedation • Reusable low compliance circuits must be used

  35. NURSING CARE • Perform through suction before connecting to the oscillator. • Assess patient upon commencement of HFOV.Monitor vital signs, chest wiggle must be evaluated upon initiation and followed closely thereafter. If chest wiggle diminishes it may be ETtube moved or obstructed. Chest wiggle on one side indicates patient developed pneumothorax,thus chest wiggle assessment should be performed after repositioning. • Auscultation the chest by putting in standby mode. • A closed suction should be used. It is not necessary to disconnect the patient to suction as this will potentially derecruit lung volumes. • The point at which the ET tube is cut and secured at lips should be initially noted this measurement is reference.

  36. Continued……… • Evaluation of lung expansion on CXR • Check capillary refill, skin color and temperature • Comparing central and peripheral pulses • Monitoring of ECG Tracing • Frequent CXR’s blood gases in initial stabilization period • Optimal lung volume for oxygenation is 8-9 rib inflation • Blood pressure and perfusion should be optimized prior to HFOV,any volume replacement should be completed and inotropes commenced if necessary

  37. Continued……… • Muscle relaxants are not indicated since spontaneous respiratory effort will be a clinical indicator of adequacy of ventilation • Sedation with opiates is often indicated THANKYOU

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