for the Life Pulse HFJV IMPORTANT Tap or click on the slide to advance Do not use the navigation arrows Clinical Simulations for the Life Pulse HFJV Instructions ID: 362548
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Slide1
Clinical Simulations
for the Life Pulse HFJV
IMPORTANT: Tap or click on the slide to advance.
Do not use the navigation arrows.Slide2
Clinical Simulations
for the Life Pulse HFJVSlide3
Instructions
Click anywhere on the slide to advanceBe 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 homepageSlide4
Patient
#1
•
24 weeks gestation
•
600 gms
•
RDS and early chronic changes post-surfactant
• Intubated, on Jet ventilatorSlide5
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 trappingSlide6
•
7.16 pH • 66 PaCO2
•
49
PaO
2
•
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%Slide7
• Raise HFJV Rate to 480 and raise FiO
2 to 36% • Raise PEEP to 7 and increase HFJV PIP to 30 • Raise CV rate to 5 and raise FiO
2
to 36%
2 hours of life
•
28
PIP
•
5
PEEP
•
2
CV IMV
•
420
bpm
•
1.8
Servo
•
26
FiO2
• 7.16 pH • 66 PaCO
2 • 49 PaO2
• 72 SaO2Slide8
‣
Raising HFJV rate would promote gas trapping ‣ Raising FiO2 may not be necessary if PEEP is optimizedSlide9
‣
Raising PEEP stabilizes alveoli Raising HFJV PIP maintains ΔP to maintain VTSlide10
‣
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 optimizedSlide11
• Lower HFJV Rate to 360 and CV to CPAP
• D/C HFJV, apply low rate, low pressure CV, and increase FiO
2
to 50%
• Wean PEEP to 6 and and raise FiO
2
to 50%
4 hours of life
•
7.27
pH
•
53
PaCO
2
•
58
PaO
2
•
85
SaO2 • 32 PIP • 7
PEEP • 2 CV IMV • 420 bpm • 2.2 Servo • 26 FiO
2Slide12
4 hours of life
• 32
PIP
•
7
PEEP
•
2
CV IMV • 420 bpm
• 2.2 Servo • 26
FiO
2
• Lower HFJV Rate to 360 and CV to CPAP
• D/C HFJV, apply low rate, low pressure CV, and increase FiO
2
to 50%
• Wean PEEP to 6 and and raise FiO
2
to 50%
•
7.27
pH
•
53 PaCO
2 • 58 PaO2
• 85 SaO2Slide13
‣
Lowering HFJV rate may reduce mild gas trapping and may stimulate baby’s spontaneous respirations ‣ Optimal PEEP eliminates the need for background IMVSlide14
‣
Returning to CV would put the baby at risk of recurring injury ‣ Increasing FiO2 may stunt alveolar growth and risks oxygen-related injurySlide15
‣
PEEP is a better way to oxygenate than is FiO2 ‣ Increasing FiO2 may stunt alveolar growth and risks oxygen-related injurySlide16
Patient
#2
• 32 weeks
• 1240 gms
• Prolonged Rupture of Membranes
• Condition digressingSlide17
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
• ABGsSlide18
Starting CV Settings
• 27
PIP
•
5
PEEP
•
32
CV Rate • 68 FiO2
• 0.4 TISlide19
30 Minutes of Life
•
7.09
pH
•
72
PaCO
2
•
57
PaO
2
•
76
SaO
2
•
27
PIP
•
5
PEEP • 32 CV Rate • 90 FiO2
• 0.4 TIWhat now?Slide20
•
100%
FiO
2
•
TcPCO
2
Climbing
• HR Dropping
• PNEUMO!
•
CT
Placed
•
Raise CV rate to 60, lower I-time to .25
• Start HFOV
• Start HFJV
1 Hour of LifeSlide21
•
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 LifeSlide22
‣
Patient has failed CV and experienced VILISlide23
‣
HFOV requires equal or greater MAP ‣ Restricted to an I:E Ratio of 1:2
‣
Minimal advantage over CV for
pneumothoracesSlide24
‣ HFJV has rich tradition of resolving airleaks ‣ HFJV is effective at lower PIPs and MAPs
‣
Can provide an I:E Ratio up to a 1:12Slide25
Starting HFJV Settings - 1 Hour of Life
HFJV
•
27
PIP
•
7
PEEP
•
300
Rate
•
0.02
T
I
•
100
FiO
2
•
27
PIP • 5 PEEP • 32 CV Rate
• 100 FiO2 • 0.4 TI0
7 CPAP
0
0
HFJV is indicated for
treating pulmonary airleaks.
CVSlide26
3 Hours of Life
• 27
PIP
•
9
PEEP
•
300
Rate • CPAP CV
• 0.02 TI
•
52
FiO
2
•
7.49
pH
•
32
PaCO
2
• 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%Slide27
3 Hours of Life
• Raise CV rate to 5, wean HFJV PIP to 24
• Wean HFJV PIP to 25 and FiO
2
to 45%
• Wean HFJV PIP to 22, FiO
2
to 45%
•
27 PIP • 9
PEEP
•
300
Rate
•
CPAP
CV
•
0.02
T
I
• 52 FiO2
•
7.49 pH • 32 PaCO2
• 87 PaO2 •
97 SaO2Slide28
‣
Raising CV rate risks Ptx reaccumulation ‣ Not necessary to raise CV rate when weaning patient from HFJVSlide29
‣
Moderate drops in HFJV PIP are appropriate for raising PaCO2 and lowering pH ‣ Wean FiO2
whenever possibleSlide30
‣
Weaning HFJV PIP too aggressively is ill advisedSmall changes in ΔP can have a significant impact on PaCO2Slide31
26 Hours of Life
•
0
PIP
•
3.5
PEEP
•
0
CV Rate • 21 FiO2
•
0
T
I
Why these settings?
EXTUBATED!Slide32
Patient
#3
• 40 weeks
• Meconium Aspiration Syndrome
• Paralyzed
• Receiving CMVSlide33
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 hemodynamic
sSlide34
•
7.07
pH
•
75
PaCO
2
•
42 PaO2 • 57
SaO2
•
26
PIP
•
5
PEEP
•
50
Rate
•
80
FiO2Pre-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 CPAPSlide35
•
26 PIP • 5 PEEP
•
50
Rate
•
80
FiO2
• PIP 35, HF Rate 420, PEEP 5, FiO
2 80, CV Rate 5
• PIP 22, HF Rate 360, PEEP 6, FiO
2
80, CV CPAP
• PIP 28, HF Rate 240, PEEP 8, FiO
2
80, CV CPAP
•
7.07
pH
•
75
PaCO
2 • 42 PaO2
• 57 SaO2
Pre-HFJV Settings on CMVSlide36
• PIP 35, HF Rate 420, PEEP 5, FiO
2
80, CV Rate 5
Promotes
Gas Trapping
Risk of
PneumothoraxSlide37
• PIP 22, HF Rate 360, PEEP 6, FiO
2
80, CV CPAPSlide38
• PIP 28, HF Rate 240, PEEP 8, FiO
2
80, CV CPAPSlide39
After 2 hours on HFJV
•
7.52
pH
•
32
PaCO
2
•
72 PaO2 •
96
SaO
2
•
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 H2OSlide40
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 H
2
O
•
7.52
pH
•
32
PaCO
2 • 72
PaO2 • 96 SaO2Slide41
‣
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 applySlide42
‣
Lower HFJV PIP in small increments ‣ Repeating blood gas rules our serendipity and reveals impact of pressure changeSlide43
‣
Too early to extubate ‣ Patient needs more time and is on very gentle lung protective ventilationSlide44
After 24 hours on HFJV
•
7.41
pH
•
38
PaCO
2
•
84 PaO2 •
96
PaO
2
•
17
PIP
•
6
PEEP
•
8
MAP • 240 Rate • CV CPAP • 24 FiO
2 • 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 5Slide45
After 24 hours on HFJV
• 17
PIP
•
6
PEEP
•
8
MAP • 240 Rate
• CV CPAP • 24
FiO
2
•
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
PaCO
2 • 84 PaO2
•
96
PaO
2Slide46
‣
Placing baby on more invasive form of ventilation, with large VT and relatively long TI, risks complicationsSlide47
‣
HFJV is already on very low “extubatable” settings (ΔP is only 9 cm H2O). ‣ Time to get the tube out!Slide48
‣
Set NCPAP level to match last MAP valueSupports adequate lung volume and oxygenationSlide49
NCPAP same as PEEP may be too low
Set NCPAP level to match last MAP valueSlide50
Congratulations
!
You have progressed successfully through these 3 challenging clinical simulations.
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