1. HFJV Introduction to HFJV

2. Overview of HFJV The Jet is composed of 5 subsystems The Jet is a microprocessor-controlled infant ventilator capable of delivering and monitoring between 240 and 660 heated, humidified breaths per minute. MONITOR: displays patient and machine pressures ALARMS: indicate potentially hazardous conditions CONTROLS: regulates the Rate, PIP and On-Time of gas flowing to the patient HUMIDIFIER: controls and monitors the temperature and humidification of the gas flowing through the humidifier and circuit PATIENT BOX: makes and monitors the breaths delivered to the patient

3. One controls the valves and other components that produce and monitor ventilation and pressure One controls and monitors humidification and temperature Two Separate Microprocessors

4. The Conventional Ventilator, when operated in tandem with the Jet, has 3 functions: The Role of the Conventional Ventilator 2.Provide background IMV breaths to open collapsed alveoli 3.Regulate PEEP to maintain alveolar recruitment 1.Provide fresh gas for a patient’s spontaneous breathing PEEP

5. The LifePort Adapter allows the Jet and conventional ventilators to be operated in tandem. The LifePort has 3 main features: The LifePort Adapter 1. 15 mm opening: provides the standard connection to the conventional ventilator 2. Jet Port: entrance for high-frequency pulses coming from the Jet 3. Pressure Monitoring Port: allows distal tip airway pressures to be approximated

6. Together, these elements form a system that offers a variety of options for managing patients. The Jet in tandem with a conventional ventilator allows the best blood gases with the least amount of pressure compared with any other form of mechanical ventilation. Summary

7. HFJV How and Why HFJV Works

8. gas is propelled into the lungs at a high velocity fresh gas penetrates through the anatomic dead space, compressing much of the CO 2 in the dead space against the airway walls incoming gas is forced to stream into the airways in a long spike abundant energy of the "jet stream" also causes the gas to spiral as it flows gas easily splits into two streams at bifurcations CO 2

9. This possibility was first illustrated as early as 1915 Henderson observed the shallow breathing of panting dogs Adequate Gas Exchange Using Small Tidal Volumes Dogs could pant indefinitely without becoming hypoxic

10. Convection penetrated smoke deeply through tubeDiffusion occurred when flow stopped or slowed

11. Convection carries fresh gas deeply into the lungs quickly Once the flow stops, diffusion completes the gas exchange process as usual The effective or physiologic dead space in the lungs can be reduced to less than the volume of the anatomic dead space The jet stream is only effective for a relatively short distance and a brief time Longer distances and times allow for development of turbulent flow Turbulent flow quickly mixes incoming gas with resident dead space gas Demonstrated Importance of Convection and Diffusion During HFJV

12. The best way to maximize the jet-stream effect with a mechanical ventilator is to place the inhalation valve as close to the patient as possible This is accomplished with HFJV by placing the valve and pressure transducer in the small plastic "patient box" that resides close to the infant's head Taking Advantage of Convection and Diffusion During HFJV The abrupt cessation of the incoming HFJV breath also helps prevent the development of turbulence so that a crisp jet stream of fresh gas can penetrate deep into the airways Gas flow through the pinch valve is stopped almost as soon as it starts by closing the valve almost as quickly

13. With HFJV, as with conventional mechanical ventilation, inhalation is active or forced, and exhalation is passive. Using rates that bring in as many as 11 breaths per second, one might be concerned that there is insufficient time for breaths to get back out. However, two factors allow exhalation to occur relatively easily. The size of each breath (1-3 mL/kg) is much smaller than usual, and the natural or resonant frequency of the infant lungs is close to the frequency range being used by HFJV. Thus, the lungs recoil readily during HFJV under almost all conditions. What About Exhalation?

14. During HFJV, exhaled gas swirls outward around the incoming gas. The exhaled gas sweeps through the CO 2 -rich deadspace gas. This action may help evacuate CO 2 and enhance ventilation. Exhalation with HFJV CO 2

15. Passive exhalation is the safest way to get gas back out of the lungs. During HFJV, passive exhalation ensures that mean airway pressure will overestimate mean alveolar pressure. Pressure drops as gas advances into the lungs on inhalation, and there is not time for the pressure in the alveoli to equilibrate with that in the upper airways because of the short inspiratory time. Furthermore, the highest pressure during exhalation will be in the alveoli so gas flows naturally toward the trachea during exhalation until the beginning of the next inhalation. More on Exhalation

16. Active exhalation, as with high-frequency oscillation (HFO), can lead to gas trapping by lowering intraluminal pressure disproportionately below pressure in surrounding alveoli, thereby collapsing more proximal airways before exhalation is complete. For that reason, users of HFO typically operate at higher mean airway pressures than those used with HFJV. Elevating the baseline pressure during HFO, "splints" the airways open while gas is actively withdrawn from alveoli. Exhalation with HFOV

17. The highest pressure in the lung during expiration is in the alveoli pressure = 0 + + + + + + + + + + + Pressure drops as gas flows out the airways

18. airways lack structural strength the chest is squeezed gas is sucked out of the airway CHOKE POINTS may develop when:

19. The high pressure in the alveoli can overwhelm the airway walls which encase gas at lower pressure + + + + + + + + +

20. Back pressure (High PEEP/Paw) may splint open the airway and allow gas to exit PEEP + + + + +

21. PEEP/Paw and the oscillatory pressure waveform must be raised to overcome gas trapping P time

22. The conventional ventilator (CV) during HFJV with the Life Pulse is to enhance oxygenation. Conventional ventilators can deliver oxygenated gas directly to the alveolar level. They do this by using relatively long (e.g., 0.5 second) inspiratory times and large tidal volumes (e.g., 7 to 15mL/kg body weight), and they have the capability of controlling end-expiratory pressure. These are the factors that most readily control PO 2. The Role of Conventional Ventilation

23. Unfortunately, the support from the CV is most closely associated with barotrauma and volutrauma. Thus, it is useful to minimize these factors by running the conventional ventilator at minimal rates (i.e., from 1 to 3 BPM) and moderate T I ’s (i.e., from.25 to.45 sec) while the Jet ventilator is providing the bulk of the ventilation. Using the conventional ventilator to gradually recruit collapsed alveoli allows the Jet to achieve the best possible blood gases with the lowest possible airway pressures. Minimizing The Risks of Conventional Ventilation

24. HFJV Technical Capabilities and Clinical Implications of HFJV

25. Technical Capability Clinical Implication Uses LifePort Adapter Minimizes mechanical dead space Allows use with any conventional ventilator Provides ability to display approximated intratracheal pressure

26. P Technical Capability Clinical Implication Operates in the natural frequency range of the lungs Minimizes pressure needed to move gas into the lungs The ease with which lungs recoil and send gas out in this frequency range lessens the chances of gas trapping that one normally encounters at higher frequencies < Natural Frequency Natural Frequency > Natural Frequency Best Blood Gases with Least Pressure

27. Technical Capability Clinical Implication Jet valve is located close to patient's airway in the Patient Box Introduces inspired gas as a sharp impulse that penetrates through the resident dead space gas Upper airway leaks (tracheal- esophageal and broncho- pleural fistulae) are bypassed by the momentum of the incoming gas.

28. Technical Capability Clinical Implication These 3 factors allow less pressure to be necessary in the treatment of lung disease Strain on the cardiopulmonary system (e.g., barotrauma and suppression of hemodynamics) is diminished Established air leaks, restrictive and/or non-homogenous such as PIE, and pneumothorax are more readily healed

29. Technical Capability Clinical Implication Pressure transducer is located in the Patient Box close to the patient with an automatic monitor- ing line purge system Allows accurate measurement of high frequency pressure fluctuations in the ET tube without interference from mucus, condensation, etc. Purge Tube Pressure Transducer Pressure Monitoring Tube

30. Technical Capability Clinical Implication Extended I:E ratios (1:1 to 1:12) with passive exhalation Gas trapping is avoided 1:6 No Gas Trapping

31. Technical Capability Clinical Implication Driving pressure is feedback controlled and alarm limits are automatically set and adjustable around this "Servo Pressure" Changes in lung compliance, pneumothoraces, and the need for suctioning may be detected Additional volume is automatic- ally provided after changes in the baby's lungs and/or leaks in the ventilator tubing or around the ET tube Volume Increases, Servo Increases Volume Decreases, Servo Decreases

32. Technical Capability Clinical Implication Gas is delivered at 100% relative humidity at body temperature via a built-in feedback controlled humidifier Continuing therapy requires minimal intervention Labor savings reduce cost of medical care delivery

33. Technical Capability Clinical Implication Ventilator tubing and humidifier circuit need only be changed every seven days All gas through the circuit is inspired gas Exhaled goes travels through the conventional ventilator circuit Patient temperature losses and airway damage is avoided.

34. Technical Capability Clinical Implication Comprehensive alarm system and fail-safe design Enhanced patient safety.

35. High Frequency Jet Ventilation: General Guidelines

36. The 6 Fundamentals 1.HFJV  P (PIP - PEEP)  PaCO 2 HFJV Rate is secondary 2.FRC and MAP  PaO 2 3.  PEEP to avoid hyperventilation and hypoxemia 4.If  CV Rate  oxygenation, PEEP is probably too low 5.  CV settings whenever possible Especially when airleaks are a concern 6.  FiO 2 before PEEP until FiO 2 < 0.5

37. 20 cm H 2 O HFJV PIP Setting CommonWhen to Raise When to Lower To raise PCO 2 (Raise PEEP if necessary to keep MAP and PO 2 constant.) To lower PCO 2

38. 420 bpm HFJV Rate Setting CommonWhen to Raise When to Lower To lengthen exhalation time and reduce inad- vertent PEEP in larger patients or when weaning To increase PCO 2 To increase MAP and PO 2 To decrease PCO 2 in smaller patients

39. 0.02 seconds HFJV I-Time Setting CommonWhen to Raise When to Lower Keep at the minimum of 0.02 in almost all cases To enable Jet to reach PIP at low HFJV rates in larger patients

40. 0 – 3 bpm CV Rate Setting Common When to Raise When to Lower Every chance you get, especially when: Airleaks are a concern Hemodynamics are compromised To reverse atelectasis

41. 15 – 20 cm H 2 O CV PIP Setting Common When to Raise When to Lower Whenever airleaks are present When you’re not seeking to recruit alveoli To reverse atelectasis

42. 0.4 seconds CV I-Time Setting Common When to Raise When to Lower Whenever airleaks are present When you’re not seeking to recruit alveoli To reverse atelectasis

43. 4 – 8 cm H 2 O PEEP Setting Common When to Raise When to Lower Usually when airleaks are present When you’re not seeking to recruit alveoli To improve oxygenation To find optimal PEEP (Raise PEEP until SaO 2 stays constant when you switch the CV to CPAP)

44. 21 – 100 % FiO 2 Setting Common When to Raise When to Lower Lower in preference to MAP until FiO 2 < 45% As needed

45. HFJV Objectives and Actions Managing Oxygenation and Ventilation During High Frequency Jet Ventilation

46. Lower PCO 2 HFJV PIP already uncomfortably high Raise HFJV Rate Note: watch for inadvertant PEEP Lower PCO 2 Raise HFJV PIP ObjectiveCircumstancesAction To Be Taken

47. ObjectiveCircumstancesAction To Be Taken Raise PO 2 Atelectasis noted on X-ray Raise the following in this order: Institute actions cautiously in infants with PAL Discontinue measures once atelectasis disappears and/or PO 2 improves Stabilize alveoli with PEEP 1. PEEP 2. CV Rate (max = 10) 3. CV PIP 4. CV I-Time CV Rate, PIP, and I-time increases are temporary Use until atelectasis is alleviated Minimize CV Rate thereafter

48. ObjectiveCircumstancesAction To Be Taken Raise PO 2 Previous actions were only temporarily successful Repeat the previous actions at a higher PEEP level Reduce MAP by decreasing CV support 1. CV Rate < 10 2. CV I-time < 0.5 sec 3. PEEP < 6 cm H 2 0 Raise PO 2 Lungs are over- expanded on X-ray 4. Raise Jet PIP to maintain PO 2

49. ObjectiveCircumstancesAction To Be Taken Raise PCO 2 Lower HFJV PIP and/or raise PEEP Raise PEEP before dropping HFJV PIP Raise PCO 2 PO 2 drops every time HFJV PIP is dropped

50. ObjectiveCircumstancesAction To Be Taken Lower PO 2 Lower, in this order, as necessary: Lower HFJV PIP Lower PO 2 PCO 2 is also low 1. FiO 2 2. CV PIP and/or Rate 3. PEEP

51. ObjectiveCircumstancesAction To Be Taken Lower PEEP Lower, in this order, as necessary: PEEP on CV has been turned down to minimum 1. HFJV On Time to 0.02 sec 2. HFJV Rate 3. IMV flow rate, if appropriate