Lung Protective Jet Ventilation

Basic Lung Protective Strategyfor

Treating RDS and Air Leakswith HFJV

Lung Protective Positive Pressure Ventilation

1. Recruit collapsed alveoli.

2. Stabilize alveoli with adequate PEEP and MAP (mean airway pressure).

3. Maintain adequate ventilation as gently as possible.

Lung Protective Ventilation with HFJV

Recruitment

Gentle Ventilation

IMV from Conventional Vent

Positive End-Expiratory (PEEP) & Mean Airway Pressure (MAP)

Stabilization

HFJV(Higher Rates Enable Smaller Tidal Volumes)

Recruitment with IMV

IMV (“Sigh” breaths) are most useful

for alveolar recruitment, but

contraindicated when airleaks are

present.

The following experiment illustrates

why...

Move your cursor over picture and click it to start video.

Double click here to continue on to next slide.

HFJV: 420 bpmPIP = 30CV:15 bpmPIP = 20

Note: CV breaths find the leak as path of least resistance while HFJV breaths continue to ventilate the other “alveoli”

Stabilization with

PEEP / MAP

Alveoli must be kept open,

whether air leaks are present or not.

HFJV = Most Gentle Ventilation

No other form of

ventilation uses smaller

tidal volumes.

HFJV uses the least overall

flow and airway pressure.

5 Keys to Optimal Patient Management

1. Start HFJV while maintaining MAP.

2. Use CV to recruit collapsed alveoli and find optimal PEEP.

3. Monitor Servo Pressure to stay on track.

5 Keys to Optimal Patient Management

4. Use HFJV rate to match lung time constants, encourage spontaneous breathing, & hasten extubation.

5. Wean to nasal CPAP.

HFJV Patient Management # 1

Don’t let MAP fall when

initiating HFJV.

Conventional HFJVP

ress

ure

Time

HFJV = Gentle Ventilation

PEEP and MAP enable Stabilization / Oxygenation

IMV enables Alveolar Recruitment

You must raise PEEP to maintain MAP for Stabilization / Oxygenation when starting HFJV.

Don’t Lose Mean Airway Pressure!

HFJV Patient Management # 2

Use Conventional Ventilator

to Recruit Alveoli and

Find Optimal PEEP

Alveolar Recruitment

Open collapsed alveoli with CV “Sigh” breaths.

V

P

Critical Opening Pressure

5

Big breaths open collapsed alveoli easier than little breaths.

CV + Low PEEP = Atelectrauma

V

P5 8

PEEP

Critical Closing Pressure

Stabilize with PEEP

Keep open alveoli from collapsing

PEEP = 5 does not work when Critical Closing Pressure = 8.

Find & Set Optimal PEEP

V

P5 9 25

Start HFJV and lower CV rate to 5 while keeping alveoli from collapsing by maintaining MAP with increased PEEP :

7

Maintain CV = 5 bpm& adjust FiO2 to stabilize SaO2 at 90%.

PEEP

Then switch CV to CPAP mode to test PEEP. Maintain HFJV at this PEEP level, weaning FiO2 to maintain target SaO2 until FiO2 ~ 30%.

Wean HFJV PIP to maintain target PCO2 .

If SaO2 falls, increase PEEP as necessary to keep SaO2 stable with HFJV + CPAP.

Does SaO2 fall when 5 IMV breaths CPAP?

Assume you started with CV and PEEP = 5, MAP = 10:

MAP

10

HFJV Patient Management # 3

Monitor Servo Pressure• If S.P. you may need to wean PIP

to keep PaCO2 and pH in target range.

• If S.P. you may need to suction, re-position ETT, or treat bronchospasms or pneumothoraces…

Reacting appropriately to Servo Pressure changes will enable continuous

Lung Protective HFJV.

V

P

Critical Closing Pressure

Gentle, open-lung, lung-protective ventilation …

HFJV Patient Management # 4

Wean to nasal CPAP.

As ventilation improves:

1. Reduce HFJV PIP first.

2. Reduce HFJV Rate to encourage spontaneous breathing.

HFJV Rate I : E

600 bpm 1 : 4

420 1 : 6

360 1 : 7

300 1 : 9

240 1 : 12

More time for spontaneous

breathing!

Warning

Reducing PIP for PCO2

also reduces MAP.

0

20

15

10

5

25

PEEP

P

Time

Reducing PIP Reduces VT (PaCO2 )

and MAP (PaO2 )PIP

MAP

HFJV Waveform

0

20

15

10

5

25

Paw

PIP

P

Time

PEEP

Reducing PIP and Raising PEEP ( VT , PaCO2 )

keeps MAP ( and hopefully PaO2 ) constant.

How can one keep MAP constant?

What if patient is hyperventilated &

hypoxemic?

0

20

15

10

5

25

PMAP

PEEP

Time

PIP

Increasing PEEP while keeping PIP constant

raises MAP ( PaO2 ) & decreases VT ( PaCO2 ).

As oxygenation improves:

1. Wean big breaths first.(Get CV into CPAP mode.)

2. Wean FiO2 before PEEP/MAP.

Wean to Nasal CPAP

You may want to offer a short trial of low rate CV or endotracheal CPAP with Jet in Standby before extubation to gauge patient’s readiness…

5

10

15

20

0.0 0.5 1.0

Time, seconds

cm H2O

P

2.01.5

It’s time to extubate when…

Patient is breathing spontaneously.HFJV PIP < 15, PEEP < 8, FiO2 < 0.3

Set Nasal CPAP = HFJV MAP

Questions?

- www.bunl.com- 800-800-HFJV

(Available 24/7)

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