1. Clinical Simulations for the Life Pulse HFJV IMPORTANT: Tap or click on the slide to advance. Do not use the navigation arrows.

2. Clinical Simulations for the Life Pulse HFJV

3. Instructions Click anywhere on the slide to advance Be sure to click on the green circles or blue navigation bars when they appear in order to advance correctly through the simulation. They will look like this: Click the Home button on the last slide to return to the Bunnell homepage

4. Patient # 1 24 weeks gestation 600 gms RDS and early chronic changes post-surfactant Intubated, on Jet ventilator

5. 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

6. 7.16 pH 66 PaCO 2 49 PaO 2 72 SaO 2 2 hours of life 28 PIP 5 PEEP 2 CV IMV 420 bpm 1.8 Servo 26 FiO 2 Raise HFJV Rate to 480 and raise FiO 2 to 36% Raise PEEP to 7 and increase HFJV PIP to 30 Raise CV rate to 5 and raise FiO 2 to 36%

7. Raise HFJV Rate to 480 and raise FiO 2 to 36% Raise PEEP to 7 and increase HFJV PIP to 30 Raise CV rate to 5 and raise FiO 2 to 36% 2 hours of life 28 PIP 5 PEEP 2 CV IMV 420 bpm 1.8 Servo 26 FiO 2 7.16 pH 66 PaCO 2 49 PaO 2 72 SaO 2

8. ‣ Raising HFJV rate would promote gas trapping ‣ Raising FiO 2 may not be necessary if PEEP is optimized

9. ‣ Raising PEEP stabilizes alveoli ‣ Raising HFJV PIP maintains ΔP to maintain V T

10. ‣ CV breaths tend to aggravate existing lung injury, create new injury, and increase risk of pulmonary airleaks. ‣ Raising FiO 2 may not be necessary if PEEP is optimized

11. Lower HFJV Rate to 360 and CV to CPAP D/C HFJV, apply low rate, low pressure CV, and increase FiO 2 to 50% Wean PEEP to 6 and and raise FiO 2 to 50% 4 hours of life 7.27 pH 53 PaCO 2 58 PaO 2 85 SaO 2 32 PIP 7 PEEP 2 CV IMV 420 bpm 2.2 Servo 26 FiO 2

12. 4 hours of life 32 PIP 7 PEEP 2 CV IMV 420 bpm 2.2 Servo 26 FiO 2 Lower HFJV Rate to 360 and CV to CPAP D/C HFJV, apply low rate, low pressure CV, and increase FiO 2 to 50% Wean PEEP to 6 and and raise FiO 2 to 50% 7.27 pH 53 PaCO 2 58 PaO 2 85 SaO 2

13. ‣ Lowering HFJV rate may reduce mild gas trapping and may stimulate baby’s spontaneous respirations ‣ Optimal PEEP eliminates the need for background IMV

14. ‣ Returning to CV would put the baby at risk of recurring injury ‣ Increasing FiO 2 may stunt alveolar growth and risks oxygen-related injury

15. ‣ PEEP is a better way to oxygenate than is FiO 2 ‣ Increasing FiO 2 may stunt alveolar growth and risks oxygen-related injury

16. Patient # 2 32 weeks 1240 gms Prolonged Rupture of Membranes Condition digressing

17. 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

18. Starting CV Settings 27 PIP 5 PEEP 32 CV Rate 68 FiO 2 0.4 T I

19. 30 Minutes of Life 7.09 pH 72 PaCO 2 57 PaO 2 76 SaO 2 27 PIP 5 PEEP 32 CV Rate 90 FiO 2 0.4 T I What now?

20. 100% FiO 2 TcPCO 2 Climbing HR Dropping PNEUMO! CT Placed Raise CV rate to 60, lower I-time to.25 Start HFOV Start HFJV 1 Hour of Life

21. 100% FiO 2 TcPCO 2 Climbing HR Dropping PNEUMO! CT Placed Raise CV rate to 60, lower I-time to.25 Start HFOV Start HFJV 1 Hour of Life

22. ‣ Patient has failed CV and experienced VILI

23. ‣ HFOV requires equal or greater MAP ‣ Restricted to an I:E Ratio of 1:2 ‣ Minimal advantage over CV for pneumothoraces

24. ‣ 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

25. Starting HFJV Settings - 1 Hour of Life HFJV 27 PIP 7 PEEP 300 Rate 0.02 T I 100 FiO 2 27 PIP 5 PEEP 32 CV Rate 100 FiO 2 0.4 T I 0 7 CPAP 0 0 HFJV is indicated for treating pulmonary airleaks. CV

26. 3 Hours of Life 27 PIP 9 PEEP 300 Rate CPAP CV 0.02 T I 52 FiO 2 7.49 pH 32 PaCO 2 87 PaO 2 97 SaO 2 Raise CV rate to 5, wean HFJV PIP to 24 Wean HFJV PIP to 25 and FiO 2 to 45% Wean HFJV PIP to 22, FiO 2 to 45%

27. 3 Hours of Life Raise CV rate to 5, wean HFJV PIP to 24 Wean HFJV PIP to 25 and FiO 2 to 45% Wean HFJV PIP to 22, FiO 2 to 45% 27 PIP 9 PEEP 300 Rate CPAP CV 0.02 T I 52 FiO 2 7.49 pH 32 PaCO 2 87 PaO 2 97 SaO 2

28. ‣ Raising CV rate risks Ptx reaccumulation ‣ Not necessary to raise CV rate when weaning patient from HFJV

29. ‣ Moderate drops in HFJV PIP are appropriate for raising PaCO 2 and lowering pH ‣ Wean FiO 2 whenever possible

30. ‣ Weaning HFJV PIP too aggressively is ill advised ‣ Small changes in ΔP can have a significant impact on PaCO 2

31. 26 Hours of Life 0 PIP 3.5 PEEP 0 CV Rate 21 FiO 2 0 T I Why these settings? EXTUBATED!

32. Patient # 3 40 weeks Meconium Aspiration Syndrome Paralyzed Receiving CMV

33. 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 hemodynamic s

34. 7.07 pH 75 PaCO 2 42 PaO 2 57 SaO 2 26 PIP 5 PEEP 50 Rate 80 FiO 2 Pre-HFJV Settings on CMV PIP 35, HF Rate 420, PEEP 5, FiO 2 80, CV Rate 5 PIP 22, HF Rate 360, PEEP 6, FiO 2 80, CV CPAP PIP 28, HF Rate 240, PEEP 8, FiO 2 80, CV CPAP

35. 26 PIP 5 PEEP 50 Rate 80 FiO 2 PIP 35, HF Rate 420, PEEP 5, FiO 2 80, CV Rate 5 PIP 22, HF Rate 360, PEEP 6, FiO 2 80, CV CPAP PIP 28, HF Rate 240, PEEP 8, FiO 2 80, CV CPAP 7.07 pH 75 PaCO 2 42 PaO 2 57 SaO 2 Pre-HFJV Settings on CMV

36. PIP 35, HF Rate 420, PEEP 5, FiO 2 80, CV Rate 5 Promotes Gas Trapping Risk of Pneumothorax

37. PIP 22, HF Rate 360, PEEP 6, FiO 2 80, CV CPAP

38. PIP 28, HF Rate 240, PEEP 8, FiO 2 80, CV CPAP

39. After 2 hours on HFJV 7.52 pH 32 PaCO 2 72 PaO 2 96 SaO 2 28 PIP 8 PEEP 240 Rate CV CPAP 50 FiO 2 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 H 2 O

40. After 2 hours on HFJV 28 PIP 8 PEEP 240 Rate CV CPAP 50 FiO 2 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 H 2 O 7.52 pH 32 PaCO 2 72 PaO 2 96 SaO 2

41. ‣ 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

42. ‣ Lower HFJV PIP in small increments ‣ Repeating blood gas rules our serendipity and reveals impact of pressure change

43. ‣ Too early to extubate ‣ Patient needs more time and is on very gentle lung protective ventilation

44. After 24 hours on HFJV 7.41 pH 38 PaCO 2 84 PaO 2 96 PaO 2 17 PIP 6 PEEP 8 MAP 240 Rate CV CPAP 24 FiO 2 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

45. After 24 hours on HFJV 17 PIP 6 PEEP 8 MAP 240 Rate CV CPAP 24 FiO 2 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 PaCO 2 84 PaO 2 96 PaO 2

46. ‣ Placing baby on more invasive form of ventilation, with large V T and relatively long T I, risks complications

47. ‣ HFJV is already on very low “extubatable” settings (ΔP is only 9 cm H 2 O). ‣ Time to get the tube out!

48. ‣ Set NCPAP level to match last MAP value ‣ Supports adequate lung volume and oxygenation

49. ‣ NCPAP same as PEEP may be too low ‣ Set NCPAP level to match last MAP value

50. Congratulations! You have progressed successfully through these 3 challenging clinical simulations. return to Bunnell home page