VDR-4 – A Case Report With additional clinical-use points David Albecker, BS, RRT-NPS, RPFT RT Clinical Programs Manager Winchester Medical Center VDR-4 – A Case Report With additional clinical-use points

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

NSTEMI 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 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/ 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

Transition to HFPV 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 Thigh phase - important for CO2 clearance in APRV 1 3100B: active exhalation can cause gas trapping in severe COPD pts2; & high, steady MAP may ↓ venous return/CO

Percussive rate (frequency/min) 600 Inspiratory Time (sec) 2 Date: 2012 4/11 4/12 4/13 4/14 4/15 4/16 4/17 4/18 Ventilator Mode VC-A/C HFPV Rate 16 22 24 15   14 PEEP 12 8 10 Tidal Volume (ml) 400 500 FiO2 0.9 1.0 0.85 0.7 0.6 0.5 0.4 Percussive rate (frequency/min) 600 Inspiratory Time (sec) 2 Expiratory Time (sec) Peak Pressure 34 pH 7.04 7.02 7.15 7.25 7.37 7.32 7.26 7.30 7.45 PaCO2 64 67 40 45 36 37 46 43 42 41 PaO2 78 71 70 87 105 90 94 58 HCO3 17 20 21 19 28 BE -14 -15 -8 -4 -7 -5 +4 SaO2 88% 87% 91% 96% 98% 95% 94% Lactate (mM/L) 2.8 2.7 1.2 0.8 on 4/23 Change made after ABG ↑ rate to 22 ↑rate to 24, ↑tidal vol to 500ml, ↑FiO2 to 1.0 change 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 8 change back to VC- A/C on 4/18

Convective Pressure Rise -How we use it- 3 pressure levels Add 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 areas Philosophy Issue: Start w/ convective rise Add it only for recruitment

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 & ABG Same for PC A/C except use PIP rather than Pplat HFPV Settings: Consider MAP & ABG on VC A/C PIP ≈ Pplat 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 FiO2 ≈ FiO2 on VC A/C Or 100% ( for transition) Convective Rise ?

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 & ABG HFPV (VDR-4) Settings: Consider MAP & ABG PIP (AIP) ≈ PHIGH from APRV Good chest rise? PEEP ≈ 10-18 Consider MAP & TLow exp flow inflection point I-Time = 2 sec E-Time = 2 sec Percussive rate=600/min FiO2 ≈ FiO2 on APRV Or 100% for transition Pinch ETT Convective Rise?

T-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

Transition from 3100B to VDR-4 in adult ICU -How we do it- Example: HFOV w/ 3100B MAP = 34 cm H2O Amplitude = 90 cm H2O Ventilation difficulty FiO2 = ? Hz = 3, 4, 5, or 6 % I-time = 33% (no concern) Cuff leak? Ventilation difficulty VDR-4 will ventilate better than 3100B Consider: tops of Amplitude pressure spikes ≈ 79 cm H2O Bottom of Amp waveform could be -10 cm H2O! 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 FiO2 (or 100% for transition) I-time= E-time = 2 sec Percussive rate = 600 Convective Rise? Pinch ETT

Alternative transition method from 3100B to VDR-4 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/FiO2 table rather than physician comfort level

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

MDI/Aerosol Bronchodilators 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

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 Decrease percussive rate from 600 to 450 (for COPD pt) Increase sinusoidal E-time allowing for better exhalation

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

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

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

INOmax w/ the VDR-4 Next 3 slides come from Brent Kenney’s presentation

INOmax w/ the VDR-4 We 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

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

A closer look at the set up w/ the INOmax

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 We have a partnership w/ VCU for ECMO pts in adult ICU

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 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

Let’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:

In our opinion: where the IPV really shines 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…

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 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

Future Plans for the VDR-4 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)

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 – Warnings; page 2. Thank You.