1. VDR-4 – A Case Report With additional clinical-use points
David Albecker, BS, RRT-NPS, RPFT RT Clinical Programs Manager Winchester Medical Center
VDR-4 – A Case Report
With additional clinical-use points

2. Conflict of Interest Statement
I have no financial interest in any device, ventilator, corporation, method, rehab facility, or therapy, mentioned in this presentation, and no conflicts of interest. David Albecker

3. NSTEMI during critical illness complicated the case
High Frequency Percussive Ventilation as Rescue Therapy for a Patient with Acute Respiratory Distress Syndrome and Septic Shock following Bilateral Pneumonia (April, 2012)
58 year old female w/ Hx of COPD and long-term tobacco use
Bilateral CAP
Septic shock → ARDS
BP ≈ 72/53
Febrile
pH ≈ 7.0
Thick, yellow pulm secretions
CXR – bilateral infiltrates all 4 lung quadrants
NSTEMI during critical illness complicated the case
IV Fluid Bolus
Multiple Antibiotics
Multiple Vasopressors
Heavy sedation
Increasing vent support w/ FiO2 of 1.0
Changed to HFPV w/ VDR-4 on day #2
6 days on VDR-4
ABG improved
FiO2 ↓ from 1.0 to 0.4
CXR improved

4. Transition to HFPV
Refractory hypoxemia that was not improving with conventional VC A/C
Copious thick, yellow pulmonary secretions
In our opinion, starting the VDR-4 in ARDS is better done sooner than later
APRV: the heavy sedation meant she would not breathe spontaneously in the Thigh phase - important for CO2 clearance in APRV 1
3100B: active exhalation can cause gas trapping in severe COPD pts2; & high, steady MAP may ↓ venous return/CO

5. Percussive rate (frequency/min) 600 Inspiratory Time (sec) 2
Date: 2012
4/11
4/12
4/13
4/14
4/15
4/16
4/17
4/18
Ventilator
Mode
VC-A/C
HFPV
Rate 16 22 24 15 14
PEEP 12 8 10
Tidal Volume (ml)
400
500
FiO2
0.9
1.0
0.85
0.7
0.6
0.5
0.4
Percussive rate (frequency/min)
600
Inspiratory Time (sec) 2
Expiratory Time (sec)
Peak Pressure 34 pH
7.04
7.02
7.15
7.25
7.37
7.32
7.26
7.30
7.45
PaCO2 64 67 40 45 36 37 46 43 42 41
PaO2 78 71 70 87
105 90 94 58
HCO3 17 20 21 19 28 BE
-14
-15 -8 -4 -7 -5 +4
SaO2
88%
87%
91%
96%
98%
95%
94%
Lactate
(mM/L)
2.8
2.7
1.2
0.8 on 4/23
Change made after ABG
↑ rate to 22
↑rate to 24, ↑tidal vol to 500ml, ↑FiO2 to 1.0
change to HFPV with VDR-4
↓ FiO2 to 0.85, ↓ percussive rate to 500/min
↓ FiO2 to 0.7
↓ FiO2 to 0.6
↓ FiO2 to 0.5
↓ FiO2 to 0.4, ↓ PEEP to 10, then 8
change back to VC- A/C on 4/18

6. Convective Pressure Rise -How we use it-
3 pressure levels
Add 5-10 cmH2O above PIP for recruitment, but you can add it without ↑PIP.
“Gives the lung time to get out of its own way”
Slow-responding lung areas
Philosophy Issue:
Start w/ convective rise
Add it only for recruitment

7. Transition From VC A/C to HFPV in Adult ICU -How we do it-
VC A/C Settings:
VT = 6ml/kg IBW
Measured Pplat = ?
Rate = ?
PEEP = ?
FiO2 = ?
Observe MAP & ABG
Same for PC A/C except use PIP rather than Pplat
HFPV Settings:
Consider MAP & ABG on VC A/C
PIP ≈ Pplat on VC A/C
Good chest rise?
PEEP ≈ PEEP on VC A/C
I-Time = 2 sec
E-Time = 2 sec
Percussive rate=600/min
FiO2 ≈ FiO2 on VC A/C
Or 100% ( for transition)
Convective Rise ?

8. Transition From APRV to HFPV in Adult ICU -How we do it-
APRV Settings:
The “Habashi way”
PHIGH = ?
PLow = 0
THigh ≈ 4-6 sec
TLow ≈ 0.8 sec
FiO2 = ?
Observe MAP & ABG
HFPV (VDR-4) Settings:
Consider MAP & ABG
PIP (AIP) ≈ PHIGH from APRV
Good chest rise?
PEEP ≈ 10-18
Consider MAP & TLow exp flow inflection point
I-Time = 2 sec
E-Time = 2 sec
Percussive rate=600/min
FiO2 ≈ FiO2 on APRV
Or 100% for transition
Pinch ETT
Convective Rise?

9. T-low expiratory flow inflection point
If pt not breathing spontaneously, hard to manage CO2 w/ APRV (heavily sedated ARDS pt)
This inflection pt determines end-exp lung volume in APRV and, w/ MAP, helps determine PEEP (AEP) setting on the VDR-4

10. Transition from 3100B to VDR-4 in adult ICU -How we do it-
Example: HFOV w/ 3100B
MAP = 34 cm H2O
Amplitude = 90 cm H2O
Ventilation difficulty
FiO2 = ?
Hz = 3, 4, 5, or 6
% I-time = 33% (no concern)
Cuff leak? Ventilation difficulty
VDR-4 will ventilate better than 3100B
Consider: tops of Amplitude pressure spikes ≈ 79 cm H2O
Bottom of Amp waveform could be -10 cm H2O!
Observe MAP & ABG
HFPV settings: remove cuff leak if it was used w/ 3100B
Consider 3100B MAP when setting VDR-4 PEEP
higher HFOV MAP → higher VDR-4 PEEP
Monitron PIP may ≈ 3100B top of Amplitude waveform
AIP on VDR-4 (sustained PIP) will be lower & clinically usable
Good chest rise?
Match FiO2 (or 100% for transition)
I-time= E-time = 2 sec
Percussive rate = 600
Convective Rise? Pinch ETT

11. Alternative transition method from 3100B to VDR-4
Observe MAP from 3100B
Set VDR-4 PEEP (AEP on Multimeter) as high as physician comfort allows
Then adjust VDR-4 PIP (AIP on Multimeter) high enough to get similar MAP as with 3100B
Downside: If you underestimate PEEP, you will overshoot on PIP in order to get target MAP – this can be similar to ARDSnet fail VC A/C w/ low PEEP and high tidal volume.
Use ARDS Peep/FiO2 table rather than physician comfort level

12. ETCO2 - Yes w/ VDR-4 Dedicated Expiratory Half-Cycle on VDR-4 allows ETCO2 measurement

13. MDI/Aerosol Bronchodilators
Delivered tidal volume w/ VDR-4 allows effective MDI/aerosol use
Similar to VC or PC w/ conventional vent
For MDI, time inhalation w/ inspiratory phase
We place MDI adaptor between Phasitron and ETT/trach
Aerosol med through Aerogen neb
We place between insp limb of circuit and green insp port of Phasitron, can also go between ETT/Trach and Phasitron

14. Ventilation and ETT Cuff Leak
Cuff Leak not required or used for ventilation w/ the VDR-4. Many better ways to ↓ CO2:
↑PIP (or ↓ PEEP if oxygenation allows) to ↑∆P
Add Convective pressure rise to ↑ ∆P
Decrease percussive rate from 600 to 450
(for COPD pt) Increase sinusoidal E-time allowing for better exhalation

15. Many ways to improve oxygenation w/ VDR-4
↑ PEEP
Add Convective Pressure Rise (recruitment maneuver)
↑ percussive rate from 600 to 750
↑ sinusoidal I-time (for pt without COPD) which creates APRV-like pressure waveform
↑ FiO2

16. Humidity w/ the VDR-4 You must pay close attention to humidity Passover + Aeroneb Solo – similar to disposable circuit + Passover
Phasitron w/ Aerogen neb
Complete circuit w/2 humidifiers
Aerogen neb
FP Passover

17. VDR-4 w/ Flolan Delivery - How we do it -
Pumps w/ Syringes
Connection to VDR-4: extension sets from syringes attach to 3-way Aeroneb Solo which runs in continuous mode
Aeroneb Driver
Flolan pump
Saline pump

18. INOmax w/ the VDR-4 Next 3 slides come from Brent Kenney’s presentation

19. INOmax w/ the VDR-4 We use this only as a back-up for Flolan in adult ICU
Adaptor placed between Phasitron and ETT/trach
Adaptor w/ connecting tubes in place

20. INOmax w/ the VDR-4
INO concentration measured in standard way but adjustments INOblender
Blended gas to INOblender, then flow out to Phasitron. Sample line to INOmax sample line inlet port.

21. A closer look at the set up w/ the INOmax

22. Guidelines for resp care in severe hypoxemic respiratory failure/ARDS
Pathway that we follow for the difficult-to-oxygenate pt
By the time we get to ECMO, we are almost always on the VDR-4
We have a partnership w/ VCU for ECMO pts in adult ICU

23. Introducing HFPV w/ the VDR-4 to an ICU with no previous experience - How we did it -
Experienced physician champion is a must (for us it was Dr Barillo)
We developed a HFPV protocol for adult ICU
I did short, introductory inservices for as many ICU nurses as possible (both shifts) on HFPV w/ VDR-4
We did more complete inservices for all ICU RTs
On a predetermined go-live date we started pt care
Yearly mandatory education is a must for ICU RTs

24. Let’s not forget the IPV – after all, it has a Phasitron too
Let’s not forget the IPV – after all, it has a Phasitron too. Our protocol algorithm:

25. In our opinion: where the IPV really shines
We have a protocol for the resp care of the spinal cord injured (SCI) pt
After the initial acute phase, how do you maintain lung clearance and expansion long-term for vent-dependent SCI pt?
IPV + Cough Assist = Perfect! Why IPV?
Next slide…

26. What does the expert say?
Kessler Institute for Rehabilitation was recently ranked #2 in USA for rehab facilities by U.S. News & World Report.
Mike Feinberg (Resp Care Manager for Kessler Institute) helped us develop our SCI protocol. Here is what he sent us:
“There is no conclusive literature that states a non surgically fixed spinal cord injury patient is safe for the vest.”
Our conclusion: This is an expert opinion and should not take the place of a review of the published studies, but we do not use any device that externally vibrates or shakes these patients (Vest, CPT thru the bed, etc).
Story of Ms. M and trauma from falling tree

27. Future Plans for the VDR-4
VDR-4 as Primary vent for status-asthmaticus pts in acute, severe respiratory failure
High energy inspiratory gas takes center of tube where resistance is the lowest.
Passive exhalation
“…all intubated asthmatics are put on the VDR. We usually start with our traditional settings, and will increase the Pulsatile flow and reduce the Oscillatory PEEP to increase the pressure gradient to overcome the high airway resistance.  That awesome “Accelerated Laminar Flow” takes over and ventilation happens.”
Denny Gish (Legacy Emanuel Med Ctr)

28. Conclusion
Questions?
We share all of our protocols. Please contact me at:
References: (from case report on slide #4)
Habashi NM. Other approaches to open-lung ventilation: Airway Pressure Release Ventilation. Crit Care Med Mar; 33(3 Suppl): S
3100B High Frequency Oscillatory Ventilator owner’s manual. CareFusion. Revision P. Chapter 1 – Warnings; page 2.
Thank You.