Lung Protective Jet Ventilation Basic Lung Protective Strategy

Lung Protective Jet Ventilation Basic Lung Protective Strategy for Treating RDS and Air Leaks with 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 IMV from Conventional Vent Stabilization Positive End-Expiratory (PEEP) & Mean Airway Pressure (MAP) Gentle Ventilation HFJV (Higher Rates Enable Smaller Tidal Volumes)

Recruitment with 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. HFJV: 420 bpm PIP = 30 CV: 15 bpm PIP = 20 Note: CV breaths find the leak as path of least resistance while HFJV breaths continue to ventilate the other “alveoli” Double click here to continue on to next slide.

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 HFJV Pressure Don’t Lose Mean Airway Pressure! IMV enables Alveolar Recruitment HFJV = Gentle Ventilation You must raise PEEP to maintain MAP for PEEP and MAP enable Stabilization / Oxygenation when starting HFJV. Time

HFJV Patient Management #2 Use Conventional Ventilator to Recruit Alveoli and Find Optimal PEEP

Alveolar Recruitment Open collapsed alveoli with CV “Sigh” breaths. Big breaths open collapsed alveoli easier than little breaths. V Critical Opening Pressure 5 P

CV + Low PEEP = Atelectrauma Keep open Critical Closing Pressure alveoli from collapsing Stabilize with PEEP = 5 does not work when Critical Closing Pressure = 8. V 5 8 P

Find & Set Optimal PEEP Assume youand started with and 5, MAP = 10: Start HFJV lower CVCV rate to PEEP 5 while= keeping alveoli from collapsing by maintaining MAP with increased PEEP : Maintain HFJV Then Maintain switch CV CVat =to 5 this CPAP bpm PEEP level, weaning mode & adjust to test. Fi. O PEEP. 2 to Fi. O stabilize Sa. O at 90%. If Sa. O falls, increase Does Sa. O 5 2 to 2 target 2 maintain 2 fall when Sa. Obreaths Fi. O 2 ~CPAP? 30%. PEEP as necessary to IMV 2 until keep 2 stable Wean. Sa. O HFJV PIP towith HFJV + CPAP. maintain target PCO. V 2 PEEP 10 57 9 MAP 25 P

HFJV Patient Management #3 Monitor Servo Pressure • If S. P. you may need to wean PIP to keep Pa. CO 2 and p. H in target range. • If S. P. you may need to suction, reposition ETT, or treat bronchospasms or pneumothoraces…

Reacting appropriately to Servo Pressure changes will enable continuous Lung Protective HFJV. Critical Closing Pressure Gentle, open-lung, lung-protective ventilation … V P

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 600 bpm 1: 4 420 1 : 6 360 1: 7 300 1: 9 I : More E time for spontaneous breathing!

Warning Reducing PIP for PCO 2 also reduces MAP.

HFJV Waveform 25 Reducing PIP Reduces VT (Pa. CO 2 ) and MAP (Pa. O 2 ) 20 PIP 15 P MAP 10 PEEP 5 0 Time

How can one keep MAP constant? Reducing PIP and Raising PEEP ( VT , Pa. CO 2 ) keeps MAP ( and hopefully Pa. O 2 ) constant. 25 P 20 PIP 15 Paw 10 PEEP 5 0 Time

What if patient is hyperventilated & hypoxemic?

Increasing PEEP while keeping PIP constant raises MAP ( Pa. O 2 ) & decreases VT ( Pa. CO 2 ). 25 P 20 PIP 15 MAP 10 PEEP 5 0 Time

As oxygenation improves: 1. Wean big breaths first. 2. (Get CV into CPAP mode. ) 2. Wean Fi. O 2 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…

It’s time to extubate when… Patient is breathing spontaneously. HFJV PIP < 15, PEEP < 8, Fi. O 2 < 0. 3 20 P Set Nasal CPAP = HFJV MAP 15 cm H 2 O 10 5 0. 0 0. 5 1. 0 Time, seconds 1. 5 2. 0

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