1. Lung Protective Jet Ventilation Basic Lung Protective Strategy for Treating RDS and Air Leaks with HFJV

2. 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.

3. Lung Protective Ventilation with HFJV Recruitment Gentle Ventilation IMV from Conventional Vent Positive End-Expiratory (PEEP) & Mean Airway Pressure (MAP) Stabilization HFJV (Higher Rates Enable Smaller Tidal Volumes)

4. Recruitment with IMV IMV (“Sigh” breaths) are most useful for alveolar recruitment, but contraindicated when airleaks are present. The following experiment illustrates why...

5. Move your cursor over picture and click it to start video. Double click here to continue on to next slide. 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”

6. Stabilization with PEEP / MAP Alveoli must be kept open, whether air leaks are present or not.

7. HFJV = Most Gentle Ventilation No other form of ventilation uses smaller tidal volumes. HFJV uses the least overall flow and airway pressure.

8. 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.

9. 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.

10. HFJV Patient Management # 1 Don’t let MAP fall when initiating HFJV.

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

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

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

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

15. Find & Set Optimal PEEP V P 5 9 25 Start HFJV and lower CV rate to 5 while keeping alveoli from collapsing by maintaining MAP with increased PEEP : 7 Maintain CV = 5 bpm & adjust FiO 2 to stabilize SaO 2 at 90%. PEEP Then switch CV to CPAP mode to test PEEP. Maintain HFJV at this PEEP level, weaning FiO 2 to maintain target SaO 2 until FiO 2 ~ 30%. Wean HFJV PIP to maintain target PCO 2. If SaO 2 falls, increase PEEP as necessary to keep SaO 2 stable with HFJV + CPAP. Does SaO 2 fall when 5 IMV breaths CPAP? Assume you started with CV and PEEP = 5, MAP = 10: MAP 10

16. HFJV Patient Management # 3 Monitor Servo Pressure If S.P. you may need to wean PIP to keep PaCO 2 and pH in target range. If S.P. you may need to suction, re- position ETT, or treat bronchospasms or pneumothoraces…

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

18. HFJV Patient Management # 4 Wean to nasal CPAP.

19. As ventilation improves: 1.Reduce HFJV PIP first. 2.Reduce HFJV Rate to encourage spontaneous breathing.

20. HFJV Rate I : E 600 bpm 1 : 4 420 1: 6 360 1 : 7 300 1 : 9 240 1 : 12 More time for spontaneous breathing!

21. Warning Reducing PIP for PCO 2 also reduces MAP.

22. 0 20 15 10 5 25 PEEP P Time Reducing PIP Reduces V T (PaCO 2 ) and MAP (PaO 2 ) PIP MAP HFJV Waveform

23. 0 20 15 10 5 25 Paw PIP P Time PEEP Reducing PIP and Raising PEEP ( V T, PaCO 2 ) keeps MAP ( and hopefully PaO 2 ) constant. How can one keep MAP constant?

24. What if patient is hyperventilated & hypoxemic?

25. 0 20 15 10 5 25 P MAP PEEP Time PIP Increasing PEEP while keeping PIP constant raises MAP ( PaO 2 ) & decreases V T ( PaCO 2 ).

26. As oxygenation improves: 1.Wean big breaths first. (Get CV into CPAP mode.) 2.Wean FiO 2 before PEEP/MAP.

27. 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…

28. 5 10 15 20 0.00.51.0 Time, seconds cm H 2 O P 2.0 1.5 It’s time to extubate when… Patient is breathing spontaneously. HFJV PIP < 15, PEEP < 8, FiO 2 < 0.3 Set Nasal CPAP = HFJV MAP

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