Presentation on theme: "VDR-4 – A Case Report With additional clinical-use points"— Presentation transcript:
1VDR-4 – A Case Report With additional clinical-use points David Albecker, BS, RRT-NPS, RPFT RT Clinical Programs Manager Winchester Medical CenterVDR-4 – A Case ReportWith additional clinical-use points
2Conflict 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
3NSTEMI during critical illness complicated the case 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 useBilateral CAPSeptic shock → ARDSBP ≈ 72/53FebrilepH ≈ 7.0Thick, yellow pulm secretionsCXR – bilateral infiltrates all 4 lung quadrantsNSTEMI during critical illness complicated the caseIV Fluid BolusMultiple AntibioticsMultiple VasopressorsHeavy sedationIncreasing vent support w/ FiO2 of 1.0Changed to HFPV w/ VDR-4 on day #26 days on VDR-4ABG improvedFiO2 ↓ from 1.0 to 0.4CXR improved
4Transition to HFPVRefractory hypoxemia that was not improving with conventional VC A/CCopious thick, yellow pulmonary secretionsIn our opinion, starting the VDR-4 in ARDS is better done sooner than laterAPRV: the heavy sedation meant she would not breathe spontaneously in the Thigh phase - important for CO2 clearance in APRV 13100B: active exhalation can cause gas trapping in severe COPD pts2; & high, steady MAP may ↓ venous return/CO
5Percussive rate (frequency/min) 600 Inspiratory Time (sec) 2 Date: 20124/114/124/134/144/154/164/174/18VentilatorModeVC-A/CHFPVRate1622241514PEEP12810Tidal Volume (ml)400500FiO20.91.00.850.70.60.50.4Percussive rate (frequency/min)600Inspiratory Time (sec)2Expiratory Time (sec)Peak Pressure34pH7.047.027.157.257.377.327.267.307.45PaCO264674045363746434241PaO278717087105909458HCO31720211928BE-14-15-8-4-7-5+4SaO288%87%91%96%98%95%94%Lactate(mM/L)188.8.131.52.8 on 4/23Change made after ABG↑ rate to 22↑rate to 24, ↑tidal vol to 500ml, ↑FiO2 to 1.0change to HFPV with VDR-4↓ FiO2 to 0.85, ↓ percussive rate to 500/min↓ FiO2 to 0.7↓ FiO2 to 0.6↓ FiO2 to 0.5↓ FiO2 to 0.4, ↓ PEEP to 10, then 8change back to VC- A/C on 4/18
6Convective Pressure Rise -How we use it- 3 pressure levelsAdd 5-10 cmH2O 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 areasPhilosophy Issue:Start w/ convective riseAdd it only for recruitment
7Transition From VC A/C to HFPV in Adult ICU -How we do it- VC A/C Settings:VT = 6ml/kg IBWMeasured Pplat = ?Rate = ?PEEP = ?FiO2 = ?Observe MAP & ABGSame for PC A/C except use PIP rather than PplatHFPV Settings:Consider MAP & ABG on VC A/CPIP ≈ Pplat on VC A/CGood chest rise?PEEP ≈ PEEP on VC A/CI-Time = 2 secE-Time = 2 secPercussive rate=600/minFiO2 ≈ FiO2 on VC A/COr 100% ( for transition)Convective Rise ?
8Transition From APRV to HFPV in Adult ICU -How we do it- APRV Settings:The “Habashi way”PHIGH = ?PLow = 0THigh ≈ 4-6 secTLow ≈ 0.8 secFiO2 = ?Observe MAP & ABGHFPV (VDR-4) Settings:Consider MAP & ABGPIP (AIP) ≈ PHIGH from APRVGood chest rise?PEEP ≈ 10-18Consider MAP & TLow exp flow inflection pointI-Time = 2 secE-Time = 2 secPercussive rate=600/minFiO2 ≈ FiO2 on APRVOr 100% for transitionPinch ETTConvective Rise?
9T-low expiratory flow inflection point If pt not breathing spontaneously, hard to manage CO2 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
10Transition from 3100B to VDR-4 in adult ICU -How we do it- Example: HFOV w/ 3100BMAP = 34 cm H2OAmplitude = 90 cm H2OVentilation difficultyFiO2 = ?Hz = 3, 4, 5, or 6% I-time = 33% (no concern)Cuff leak? Ventilation difficultyVDR-4 will ventilate better than 3100BConsider: tops of Amplitude pressure spikes ≈ 79 cm H2OBottom of Amp waveform could be -10 cm H2O!Observe MAP & ABGHFPV settings: remove cuff leak if it was used w/ 3100BConsider 3100B MAP when setting VDR-4 PEEPhigher HFOV MAP → higher VDR-4 PEEPMonitron PIP may ≈ 3100B top of Amplitude waveformAIP on VDR-4 (sustained PIP) will be lower & clinically usableGood chest rise?Match FiO2 (or 100% for transition)I-time= E-time = 2 secPercussive rate = 600Convective Rise? Pinch ETT
11Alternative transition method from 3100B to VDR-4 Observe MAP from 3100BSet VDR-4 PEEP (AEP on Multimeter) as high as physician comfort allowsThen adjust VDR-4 PIP (AIP on Multimeter) high enough to get similar MAP as with 3100BDownside: 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/FiO2 table rather than physician comfort level
13MDI/Aerosol Bronchodilators Delivered tidal volume w/ VDR-4 allows effective MDI/aerosol useSimilar to VC or PC w/ conventional ventFor MDI, time inhalation w/ inspiratory phaseWe place MDI adaptor between Phasitron and ETT/trachAerosol med through Aerogen nebWe place between insp limb of circuit and green insp port of Phasitron, can also go between ETT/Trach and Phasitron
14Ventilation 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 ↑∆PAdd Convective pressure rise to ↑ ∆PDecrease percussive rate from 600 to 450(for COPD pt) Increase sinusoidal E-time allowing for better exhalation
15Many ways to improve oxygenation w/ VDR-4 ↑ PEEPAdd 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
16Humidity w/ the VDR-4 You must pay close attention to humidity Passover + Aeroneb Solo – similar to disposable circuit + PassoverPhasitron w/ Aerogen nebComplete circuit w/2 humidifiersAerogen nebFP Passover
17VDR-4 w/ Flolan Delivery - How we do it - Pumps w/ SyringesConnection to VDR-4: extension sets from syringes attach to 3-way Aeroneb Solo which runs in continuous modeAeroneb DriverFlolan pumpSaline pump
18INOmax w/ the VDR-4 Next 3 slides come from Brent Kenney’s presentation
19INOmax w/ the VDR-4 We use this only as a back-up for Flolan in adult ICU Adaptor placed between Phasitron and ETT/trachAdaptor w/ connecting tubes in place
20INOmax w/ the VDR-4INO concentration measured in standard way but adjustments INOblenderBlended gas to INOblender, then flow out to Phasitron. Sample line to INOmax sample line inlet port.
22Guidelines for resp care in severe hypoxemic respiratory failure/ARDS Pathway that we follow for the difficult-to-oxygenate ptBy the time we get to ECMO, we are almost always on the VDR-4We have a partnership w/ VCU for ECMO pts in adult ICU
23Introducing 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 ICUI did short, introductory inservices for as many ICU nurses as possible (both shifts) on HFPV w/ VDR-4We did more complete inservices for all ICU RTsOn a predetermined go-live date we started pt careYearly mandatory education is a must for ICU RTs
24Let’s not forget the IPV – after all, it has a Phasitron too Let’s not forget the IPV – after all, it has a Phasitron too. Our protocol algorithm:
25In our opinion: where the IPV really shines We have a protocol for the resp care of the spinal cord injured (SCI) ptAfter 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…
26What 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 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
27Future Plans for the VDR-4 VDR-4 as Primary vent for status-asthmaticus pts in acute, severe respiratory failureHigh 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)
28ConclusionQuestions?We share all of our protocols. Please contact me at:References: (from case report on slide #4)Habashi NM. Other approaches to open-lung ventilation: Airway Pressure Release Ventilation. Crit Care Med Mar; 33(3 Suppl): S3100B High Frequency Oscillatory Ventilator owner’s manual. CareFusion. Revision P. Chapter 1 – Warnings; page 2.Thank You.