Presentation on theme: "David Albecker, BS, RRT-NPS, RPFT RT Clinical Programs Manager Winchester Medical Center."— Presentation transcript:
David Albecker, BS, RRT-NPS, RPFT RT Clinical Programs Manager Winchester Medical Center
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
58 year old female w/ Hx of COPD and long-term tobacco use Bilateral CAP Septic shock → ARDS – BP ≈ 72/53 – Febrile – pH ≈ 7.0 – Thick, yellow pulm secretions – CXR – bilateral infiltrates all 4 lung quadrants NSTEMI during critical illness complicated the case IV Fluid Bolus Multiple Antibiotics Multiple Vasopressors Heavy sedation Increasing vent support w/ FiO 2 of 1.0 Changed to HFPV w/ VDR-4 on day #2 6 days on VDR-4 – ABG improved – FiO 2 ↓ from 1.0 to 0.4 – CXR improved
Refractory hypoxemia that was not improving with conventional VC A/C Copious thick, yellow pulmonary secretions In our opinion, starting the VDR-4 in ARDS is better done sooner than later APRV: the heavy sedation meant she would not breathe spontaneously in the T high phase - important for CO 2 clearance in APRV B: active exhalation can cause gas trapping in severe COPD pts 2 ; & high, steady MAP may ↓ venous return/CO
Date: 20124/11 4/12 4/134/144/154/164/174/18 Ventilator Mode VC-A/C HFPV VC-A/C Rate PEEP Tidal Volume (ml) FiO Percussive rate (frequency/min) Inspiratory Time (sec) Expiratory Time (sec) Peak Pressure 34 pH PaCO PaO HCO BE SaO 2 88%87%88%91%96%98%95%96%87%94% Lactate (mM/L) on 4/23 Change made after ABG ↑ rate to 22 ↑rate to 24, ↑tidal vol to 500ml, ↑FiO 2 to 1.0 change to HFPV with VDR-4 ↓ FiO 2 to 0.85, ↓ percussive rate to 500/min ↓ FiO 2 to 0.7 ↓ FiO 2 to 0.6 ↓ FiO 2 to 0.5 ↓ FiO 2 to 0.4, ↓ PEEP to 10, then 8 change back to VC- A/C on 4/18
Add 5-10 cmH 2 O above PIP for recruitment, but you can add it without ↑PIP. “Gives the lung time to get out of its own way” – Slow-responding lung areas Philosophy Issue: – Start w/ convective rise – Add it only for recruitment 3 pressure levels
VC A/C Settings: – VT = 6ml/kg IBW – Measured P plat = ? – Rate = ? – PEEP = ? – FiO 2 = ? – Observe MAP & ABG Same for PC A/C except use PIP rather than P plat HFPV Settings: – Consider MAP & ABG on VC A/C PIP ≈ P plat on VC A/C – Good chest rise? PEEP ≈ PEEP on VC A/C I-Time = 2 sec – E-Time = 2 sec – Percussive rate=600/min FiO 2 ≈ FiO 2 on VC A/C – Or 100% ( for transition) Convective Rise ?
APRV Settings: The “Habashi way” – P HIGH = ? – P Low = 0 – T High ≈ 4-6 sec – T Low ≈ 0.8 sec – FiO 2 = ? – Observe MAP & ABG HFPV (VDR-4) Settings: – Consider MAP & ABG PIP (AIP) ≈ P HIGH from APRV – Good chest rise? PEEP ≈ – Consider MAP & T Low exp flow inflection point I-Time = 2 sec – E-Time = 2 sec – Percussive rate=600/min FiO 2 ≈ FiO 2 on APRV – Or 100% for transition Pinch ETT Convective Rise?
If pt not breathing spontaneously, hard to manage CO 2 w/ APRV (heavily sedated ARDS pt ) This inflection pt determines end-exp lung volume in APRV and, w/ MAP, helps determine PEEP (AEP) setting on the VDR-4
Example: HFOV w/ 3100B – MAP = 34 cm H 2 O – Amplitude = 90 cm H 2 O Ventilation difficulty – FiO 2 = ? – Hz = 3, 4, 5, or 6 Ventilation difficulty – % I-time = 33% (no concern) – Cuff leak? Ventilation difficulty VDR-4 will ventilate better than 3100B Consider: tops of Amplitude pressure spikes ≈ 79 cm H 2 O – Bottom of Amp waveform could be -10 cm H 2 O! Observe MAP & ABG HFPV settings: remove cuff leak if it was used w/ 3100B Consider 3100B MAP when setting VDR-4 PEEP – higher HFOV MAP → higher VDR-4 PEEP Monitron PIP may ≈ 3100B top of Amplitude waveform – AIP on VDR-4 (sustained PIP) will be lower & clinically usable – Good chest rise? Match FiO 2 (or 100% for transition) I-time= E-time = 2 sec – Percussive rate = 600 Convective Rise? Pinch ETT
Observe MAP from 3100B Set VDR-4 PEEP (AEP on Multimeter) as high as physician comfort allows Then adjust VDR-4 PIP (AIP on Multimeter) high enough to get similar MAP as with 3100B Downside: If you underestimate PEEP, you will overshoot on PIP in order to get target MAP – this can be similar to ARDSnet fail VC A/C w/ low PEEP and high tidal volume. – Use ARDS Peep/FiO 2 table rather than physician comfort level
Delivered tidal volume w/ VDR-4 allows effective MDI/aerosol use Similar to VC or PC w/ conventional vent For MDI, time inhalation w/ inspiratory phase – We place MDI adaptor between Phasitron and ETT/trach Aerosol med through Aerogen neb – We place between insp limb of circuit and green insp port of Phasitron, can also go between ETT/Trach and Phasitron
Cuff Leak not required or used for ventilation w/ the VDR-4. Many better ways to ↓ CO 2 : ↑PIP (or ↓ PEEP if oxygenation allows) to ↑∆P Add Convective pressure rise to ↑ ∆P Decrease percussive rate from 600 to 450 (for COPD pt) Increase sinusoidal E-time allowing for better exhalation
↑ 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 ↑ FiO 2
Pumps w/ Syringes Connection to VDR-4: extension sets from syringes attach to 3-way Aeroneb Solo which runs in continuous mode Flolan pump Saline pump Aeroneb Driver
Adaptor placed between Phasitron and ETT/trach Adaptor w/ connecting tubes in place
Blended gas to INOblender, then flow out to Phasitron. Sample line to INOmax sample line inlet port. INO concentration measured in standard way but adjustments INOblender
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 We have a partnership w/ VCU for ECMO pts in adult ICU
Experienced physician champion is a must (for us it was Dr Barillo) We developed a HFPV protocol for adult ICU I did short, introductory inservices for as many ICU nurses as possible (both shifts) on HFPV w/ VDR-4 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
We have a protocol for the resp care of the spinal cord injured (SCI) pt After the initial acute phase, how do you maintain lung clearance and expansion long- term for vent-dependent SCI pt? IPV + Cough Assist = Perfect! Why IPV? – Next slide…
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 sent us: – “There is no conclusive literature that states a non surgically fixed spinal cord injury patient is safe for the vest.” Our 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). Story of Ms. M and trauma from falling tree
VDR-4 as Primary vent for status-asthmaticus pts in acute, severe respiratory failure High energy inspiratory gas takes center of tube where resistance is the lowest. Passive exhalation “…all intubated asthmatics are put on the VDR. We usually start with our traditional settings, and will increase the Pulsatile flow and reduce the Oscillatory PEEP to increase the pressure gradient to overcome the high airway resistance. That awesome “Accelerated Laminar Flow” takes over and ventilation happens.” – Denny Gish (Legacy Emanuel Med Ctr)
Questions? We share all of our protocols. Please contact me at: References: (from case report on slide #4) 1.Habashi NM. Other approaches to open-lung ventilation: Airway Pressure Release Ventilation. Crit Care Med Mar; 33(3 Suppl): S B High Frequency Oscillatory Ventilator owner’s manual. CareFusion. Revision P. Chapter 1 – Warnings; page 2. Thank You.