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

2. 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

5. ECMO Mobile Surgical Transport Team

7. Bronchotron with circuit

8. Disposable bronchotron circuit

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

10. 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.

11. 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

12. Laminar flow enhanced with entrainment of gas

17. 17

18. 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.

19. 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

20. Increase PaO2 only
Check patient; (hemodynamic status, blood, fluid levels etc)
Increase FiO2
Increase Oscillatory CPAP (peep); 2cmH2O steps, max 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

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

23. 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

24. 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 60 bpm, with a pip of 30 and varying peep.

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

27. Settings You Manipulate
Initial settings:
Settings you don’t generally manipulate
High frequency percussive rate=
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.

28. 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%.

29. 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

30. X-ray looks like….
meconium

31. 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.

32. 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%

33. 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.

34. NO delivery on transport

38. How about aerosolized continuous epoprostenol (Veletri)?

39. 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%

40. 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)

41. 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?

43. Rotoflow
console

44. Rotoflow
console
pump head

45. Rotoflow
console
pump head
oxygenator

46. ECMO Mobile Surgical Transport Team

47. ECMO Mobile Surgical Transport Team
TRN
OR RN

48. ECMO Mobile Surgical Transport Team
TRN
OR RN
RRT

49. ECMO Mobile Surgical Transport Team
TRN
OR RN
RRT
perfusion

50. ECMO Mobile Surgical Transport Team
TRN
OR RN
RRT
perfusion
surgeon

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

53. How about walking an Ecmo patient to the Garden?

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

56. 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.

57. Thank you for your time!