Acute Care Transport from Neonate to Adult By Jeff Heltborg Respiratory Clinical Specialist Legacy Emanuel and Randall Children’s Hospital Portland , Oregon

Objectives Identify types of patients that would benefit from this style of ventilation. Explore nitric oxide delivery and aerosolized epoprostenol with this device and feasibility. Explore continuous nebs with this device

ECMO Mobile Surgical Transport Team

Bronchotron with circuit

Disposable bronchotron circuit

Transporting with high Frequency Ventilators Not easy(logistics) Usually use large amounts of gas Small percentage of transports

High Frequency Percussive Ventilation HFPV -High Frequency Percussive Ventilation (HFPV) is a hybrid form of high frequency ventilation. -This concept of pneumatic diffusive / convective protocols is not related to high frequency vibration, jet insufflation or electronically controlled crank or magnetically servoed dynamic oscillators.

The Phasitron; The patient interface A Sliding Venturi “floating” exhalation valve Entrains during inspiratory Entrains up to 1:5 Pneumatic clutch – “feels” backpressure Open to ambient during expiratory Flow to pressure / pressure to flow converter 7ms transition penalty Allows theoretical rates up to 7200 bpm

Laminar flow enhanced with entrainment of gas

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Sinusoidal Bronchotron INITIAL SETTINGS for patients<5 kg. Conventional Breath PIP (pulsatile flow) 14-20 For chest expansion FIO2 As Needed INSPIRATORY TIME 1 second EXPIRATORY TIME RESPIRATORY RATE 30 bpm High Frequency Breath PULSE FREQUENCY 600bpm + 75 Oscillatory Peep 6 <5 kg.

Decrease PaCO2, only Increase pulsatile flow (pip) in steps of 2 cmH2O. Remember pressure at carina is 1/3 lower than what is set on ventilator Check for cuff leak if applicable. Decreased CO2 with increased leak. (variable results) 19

Increase PaO2 only Check patient; (hemodynamic status, blood, fluid levels etc) Increase FiO2 Increase Oscillatory CPAP (peep); 2cmH2O steps, max 8-12 for neonates Increase Pulsatile flow in increments of two as long as CO2 is not too low With this check Pulmonary Artery pressure, Blood Pressure, Heart rate, O2 Saturation, Mean Airway pressure. 20

Increase PaO2 AND drop PaCO2 Increase pulsatile flow (pip)in 2 cm increments. Will potentially increase Map. 21

A 840 gm baby delivered via stat c-section for poor fetal tones. The child was intubated with 2.5 ett post poor effort during resuscitation. UAC placed with difficulty. Initial gas=7.11, CO2=85, PO2=48, bicarb=19 You get called to transport patient back

Patient placed on Drager babylog. Settings are:mode- psv/vg rr=50, vt=4.5, peep=5, fio2=70%, Sao2=88 Pt’s uac = 7.20, CO2=75,PO2=60,Bicarb=20 While we were driving there they gave surfactant and now they have to bag the baby as they can’t keep the saO2 elevated. You walk in and they are bagging the baby @ 60 bpm, with a pip of 30 and varying peep.

What settings should we use? We place the patient on the sinosoidal bronchotron. What settings should we use?

Settings You Manipulate Initial settings: Settings you don’t generally manipulate High frequency percussive rate=500 + 75 Conventional Rate=30 Inspiratory and expiratory time for conventional rate=1 second for each parameter Settings You Manipulate Pulsatile flow-16 (or 14 with gentle chest rise) Peep-6 FiO2-variable for SaO2 goals (in this case 60%) With first abg and following abg’s watch for hyper ventilation. This ventilator is very efficient in removing CO2.

First blood gas= ph-7.18, CO2-79, O2-68, Bicarb-20 Sa02=89 What do we manipulate? Increase Pulsatile flow by two. Leave every thing else the same. Next abg=ph-7.27, CO2-60, O2-44, Bicarb-21 Sao2=80 What do we manipulate? Increase Peep by two to 8 or increase fiO2 depending on management style for fiO2 above 60%.

Term Meconium Term infant with thick meconium that was precipitously delivered. Resuscitation went poorly and now child is two days old and on 3100 A with NO and stuck on 90%. Abg=7.24,CO2=80,O2=39 3100A settings=map-20, delta p-46, hz-8, NO=20ppm. We will transport this patient for possible ECMO

X-ray looks like…. meconium

1st thought Try to match settings. With transport bronchotron Primarily the same map if possible. Initial Settings: Percussive rate-500, convective rate-30, Inspiratory and expiratory time-1 second Pulsatile flow(pip)-26 look for gentle chest rise Peep-10, FiO2=90%, NO=20ppm Look at the mean on the guage and watch bp. Grab a chest x- ray if there is time.

Initial abg =7.29, CO2=60, O2=29, SaO2=80 What do we manipulate? Do we have chest rise? If yes then just increase the peep by two, if not then increase both the pulsatile flow and the peep by two. In this case, not much chest rise so did both Next abg=7.30, CO2=56, O2=32, SaO2=82 Patient’s bp drops significantly and sao2=45%

What to do We started bagging and gave fluid bolus and increased both our dopamine and dobutamine levels. Once fluid bolus in, then placed back on ventilator and same settings. X-ray is back and does not show overdistension. Sao2 is now 88%. Grabbed one more gas, packed up and got the heck out of Dodge while we could.

NO delivery on transport

How about aerosolized continuous epoprostenol (Veletri)?

How big can a patient be? In 2009 we initiated mobile ECMO for adult patients with H1N1. Three weeks later after decision was made we received our first transport request. First patient was 300 pound 34 y.o. male on 3100 B oscillator with nitric. 3100 B map=40, delta p=96, hz =3 pt’s sao2=84%

How do you match those settings 3100 settings: Map=40 , amplitude = 96, hz=3 Bronchotron settings to match map: Pulsatile flow =56, osclilatory cpap (peep)=18 High freq. rate=500, convective rate=15 map=36 I time = 2 seconds E time = 2 seconds Sao2 increases to 96% in 15 minutes. Not the end of the story (never is)

Adult Mobile Ecmo and adult Rescue Ventilator Transports In the last 4 years we have done over 36 mobile ECMO transports and /or Adult rescue Ventilator Transports. Well what does it look like?

Rotoflow console

Rotoflow console pump head

Rotoflow console pump head oxygenator

ECMO Mobile Surgical Transport Team

ECMO Mobile Surgical Transport Team TRN OR RN

ECMO Mobile Surgical Transport Team TRN OR RN RRT

ECMO Mobile Surgical Transport Team TRN OR RN RRT perfusion

ECMO Mobile Surgical Transport Team TRN OR RN RRT perfusion surgeon

ECMO Mobile Surgical Transport Team TRN OR RN RRT perfusion surgeon driver

How about walking an Ecmo patient to the Garden?

How furry can a patient be? Only a guy from Oregon would ask this!!!!!

Conclusion Percussive ventilation can be used on transport with the bronchotron for a variety of patients to include neonates from 800 grams to 300 pound adults. Accelerated laminar flow is an effective way to remove both debris and CO2 from the lung while positively affecting oxygenation.

Thank you for your time!