Clinical Simulationsfor the

Life Pulse HFJV

IMPORTANT: Tap or click on the slide to advance. Do not use the navigation arrows.

Clinical Simulationsfor the

Life Pulse HFJV

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

Patient #1• 24 weeks gestation

• 600 gms

• RDS and early chronic changes post-surfactant

• Intubated, on Jet ventilator

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

• 7.16 pH• 66 PaCO2

• 49 PaO2

• 72 SaO2

2 hours of life

•28 PIP• 5 PEEP • 2 CV IMV•420 bpm•1.8 Servo•26 FiO2

• Raise HFJV Rate to 480 and raise FiO2 to 36%

• Raise PEEP to 7 and increase HFJV PIP to 30

• Raise CV rate to 5 and raise FiO2 to 36%

• Raise HFJV Rate to 480 and raise FiO2 to 36%

• Raise PEEP to 7 and increase HFJV PIP to 30

• Raise CV rate to 5 and raise FiO2 to 36%

2 hours of life

•28 PIP• 5 PEEP • 2 CV IMV•420 bpm•1.8 Servo•26 FiO2

• 7.16 pH• 66 PaCO2

• 49 PaO2

• 72 SaO2

‣ Raising HFJV rate would promote gas trapping

‣ Raising FiO2 may not be necessary if PEEP is optimized

‣ Raising PEEP stabilizes alveoli

‣ Raising HFJV PIP maintains ΔP to maintain VT

‣ CV breaths tend to aggravate existing lung injury, create new injury, and increase risk of pulmonary airleaks.

‣ Raising FiO2 may not be necessary if PEEP is optimized

• Lower HFJV Rate to 360 and CV to CPAP

• D/C HFJV, apply low rate, low pressure CV, and increase FiO2 to 50%

• Wean PEEP to 6 and and raise FiO2 to 50%

4 hours of life

• 7.27 pH• 53 PaCO2

• 58 PaO2

• 85 SaO2

•32 PIP• 7 PEEP • 2 CV IMV•420 bpm•2.2 Servo•26 FiO2

4 hours of life

•32 PIP• 7 PEEP • 2 CV IMV•420 bpm•2.2 Servo•26 FiO2

• Lower HFJV Rate to 360 and CV to CPAP

• D/C HFJV, apply low rate, low pressure CV, and increase FiO2 to 50%

• Wean PEEP to 6 and and raise FiO2 to 50%

• 7.27 pH• 53 PaCO2

• 58 PaO2

• 85 SaO2

‣ Lowering HFJV rate may reduce mild gas trapping and may stimulate baby’s spontaneous respirations

‣ Optimal PEEP eliminates the need for background IMV

‣ Returning to CV would put the baby at risk of recurring injury

‣ Increasing FiO2 may stunt alveolar growth and risks oxygen-related injury

‣ PEEP is a better way to oxygenate than is FiO2

‣ Increasing FiO2 may stunt alveolar growth and risks oxygen-related injury

Patient #2• 32 weeks

• 1240 gms

• Prolonged Rupture of Membranes

• Condition digressing

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

Starting CV Settings

• 27 PIP• 5 PEEP• 32 CV Rate• 68 FiO2

• 0.4 TI

30 Minutes of Life

• 7.09 pH• 72 PaCO2

• 57 PaO2

• 76 SaO2

• 27 PIP• 5 PEEP• 32 CV Rate• 90 FiO2

• 0.4 TI

What now?

• 100% FiO2

• TcPCO2 Climbing• HR Dropping• PNEUMO!• CT Placed

• Raise CV rate to 60, lower I-time to .25

• Start HFOV

• Start HFJV

1 Hour of Life

• 100% FiO2

• TcPCO2 Climbing• HR Dropping• PNEUMO!• CT Placed

• Raise CV rate to 60, lower I-time to .25

• Start HFOV

• Start HFJV

1 Hour of Life

‣ Patient has failed CV and experienced VILI

‣ HFOV requires equal or greater MAP

‣ Restricted to an I:E Ratio of 1:2

‣ Minimal advantage over CV for pneumothoraces

‣ 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

Starting HFJV Settings - 1 Hour of Life

HFJV

• 27 PIP• 7 PEEP• 300 Rate• 0.02 TI

• 100 FiO2

• 27 PIP• 5 PEEP• 32 CV Rate• 100 FiO2

• 0.4 TI

0 7 CPAP0

0

HFJV is indicated fortreating pulmonary airleaks.

CV

3 Hours of Life

• 27 PIP• 9 PEEP• 300 Rate• CPAP CV• 0.02 TI

• 52 FiO2

• 7.49 pH• 32 PaCO2

• 87 PaO2

• 97 SaO2

• Raise CV rate to 5, wean HFJV PIP to 24

• Wean HFJV PIP to 25 and FiO2 to 45%

• Wean HFJV PIP to 22, FiO2 to 45%

3 Hours of Life

• Raise CV rate to 5, wean HFJV PIP to 24

• Wean HFJV PIP to 25 and FiO2 to 45%

• Wean HFJV PIP to 22, FiO2 to 45%

• 27 PIP• 9 PEEP• 300 Rate• CPAP CV• 0.02 TI

• 52 FiO2

• 7.49 pH• 32 PaCO2

• 87 PaO2

• 97 SaO2

‣ Raising CV rate risks Ptx reaccumulation

‣ Not necessary to raise CV rate when weaning patient from HFJV

‣ Moderate drops in HFJV PIP are appropriate for raising PaCO2 and lowering pH

‣ Wean FiO2 whenever possible

‣ Weaning HFJV PIP too aggressively is ill advised

‣ Small changes in ΔP can have a significant impact on PaCO2

26 Hours of Life• 0 PIP•3.5 PEEP• 0 CV Rate• 21 FiO2

• 0 TI

Why these settings?

EXTUBATED!

Patient #3• 40 weeks

• Meconium Aspiration Syndrome

• Paralyzed

• Receiving CMV

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

hemodynamics

• 7.07 pH• 75 PaCO2

• 42 PaO2

• 57 SaO2

•26 PIP•5 PEEP •50 Rate•80 FiO2

Pre-HFJV Settings on CMV

• PIP 35, HF Rate 420, PEEP 5, FiO2 80, CV Rate 5

• PIP 22, HF Rate 360, PEEP 6, FiO2 80, CV CPAP

• PIP 28, HF Rate 240, PEEP 8, FiO2 80, CV CPAP

•26 PIP•5 PEEP •50 Rate•80 FiO2

• PIP 35, HF Rate 420, PEEP 5, FiO2 80, CV Rate 5

• PIP 22, HF Rate 360, PEEP 6, FiO2 80, CV CPAP

• PIP 28, HF Rate 240, PEEP 8, FiO2 80, CV CPAP

• 7.07 pH• 75 PaCO2

• 42 PaO2

• 57 SaO2

Pre-HFJV Settings on CMV

• PIP 35, HF Rate 420, PEEP 5, FiO2 80, CV Rate 5

PromotesGas Trapping

Risk ofPneumothorax

• PIP 22, HF Rate 360, PEEP 6, FiO2 80, CV CPAP

• PIP 28, HF Rate 240, PEEP 8, FiO2 80, CV CPAP

After 2 hours on HFJV

• 7.52 pH• 32 PaCO2

• 72 PaO2

• 96 SaO2

• 28 PIP• 8 PEEP• 240 Rate • CV CPAP• 50 FiO2

• 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 H2O

After 2 hours on HFJV

• 28 PIP• 8 PEEP• 240 Rate • CV CPAP• 50 FiO2

• 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 H2O

• 7.52 pH• 32 PaCO2

• 72 PaO2

• 96 SaO2

‣ 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

‣ Lower HFJV PIP in small increments

‣ Repeating blood gas rules our serendipity and reveals impact of pressure change

‣ Too early to extubate

‣ Patient needs more time and is on very gentle lung protective ventilation

After 24 hours on HFJV

• 7.41 pH• 38 PaCO2

• 84 PaO2

• 96 PaO2

• 17 PIP• 6 PEEP• 8 MAP• 240 Rate • CV CPAP• 24 FiO2

• 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

After 24 hours on HFJV

• 17 PIP• 6 PEEP• 8 MAP• 240 Rate • CV CPAP• 24 FiO2

• 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 PaCO2

• 84 PaO2

• 96 PaO2

‣ Placing baby on more invasive form of ventilation, with large VT and relatively long TI, risks complications

‣ HFJV is already on very low “extubatable” settings (ΔP is only 9 cm H2O).

‣ Time to get the tube out!

‣ Set NCPAP level to match last MAP value

‣ Supports adequate lung volume and oxygenation

‣ NCPAP same as PEEP may be too low

‣ Set NCPAP level to match last MAP value

Congratulations!You have progressed successfully

through these 3 challenging clinical simulations.

return to Bunnell home page