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High Frequency Oscillatory Ventilation in Pediatric Patients

John H. Arnold, MD Department of Anesthesia, Childrens Hospital Boston and the Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, MA

Data supporting the feasibility of ventilating effectively with very small tidal volumes comes from the observation that the need for adequate bulk gas flow in airways can be achieved by delivering tidal volumes approximating the dead space at high frequency. While attempting to measure cardiac performance in large animals by assessing the myocardial response to pericardial pressure oscillations, Lunkenheimer and colleagues found in the early 1970s that endotracheal high frequency oscillations could produce efficient CO2 elimination in the absence of significant chest wall excursion. These investigators determined that CO2 elimination was related to changes in the frequency of oscillation as well as the amplitude of the vibrations. In general, CO2 was cleared optimally at a frequency between 23-40 Hz, with smaller animals requiring higher frequencies. Several years later, Butler and colleagues observed that gas exchange could be supported in humans using frequencies up to 15 Hz, hypothesizing that this would enhance diffusive gas transport while minimizing dependence on bulk convective gas flow in the airways. In this report, a series of patients 9 years of age and older in an intensive care unit was successfully ventilated with tidal volumes in the range of 50-100cc. At the moment, there is a great deal of laboratory data to suggest that repetitive cycles of pulmonary recruitment and derecruitment are associated with identifiable markers of lung injury, and experimental models of ventilatory support which reverse atelectasis, limit phasic changes in lung volume, and prevent alveolar overdistention appear to be less injurious. In addition, recent clinical investigations have brought about an understanding that specific strategies for mechanical ventilation can have an important influence on outcomes in patients with the acute respiratory distress syndrome (ARDS). In 2000, the ARDSnetwork demonstrated a 22% relative reduction in mortality among adult patients with ARDS on conventional mechanical ventilation who were randomized to receive relatively small tidal volumes (6 cc/kg ideal body weight), compared to those who were ventilated with larger tidal volumes (12 cc/kg ideal body weight). These observations have led to the expectation that high frequency ventilation could limit excess lung injury in the clinical arena because of its ability to provide efficient, low-stretch ventilation in the setting of continuous alveolar recruitment. This open-lung strategy of ventilation offers the promise of lung protection by its ability to preserve end-expiratory lung volume, minimize cyclic stretch, and avoid parenchymal overdistension at end-inspiration by limiting tidal volume and transpulmonary pressure. The major modalities of high frequency ventilation include high frequency flow interruption (HFFI), high frequency positive pressure ventilation (HFPPV), high frequency jet ventilation (HFJV), and high frequency oscillatory ventilation (HFOV). HFOV is the most widely used form of high frequency ventilation in clinical practice today, and in this mode, lung recruitment is maintained by the application of relatively high mean airway pressure, while ventilation is achieved by superimposed sinusoidal pressure oscillations that are delivered by a motor-driven piston or diaphragm at a frequency of 3-15 Hz. HFOV is the only form of high frequency ventilation in which expiration is an active process. As a result, alveolar ventilation is achieved during HFOV with the use of tidal volumes in the range of 1-3 cc/kg, even in the most poorly compliant lung.

Summary of neonatal and pediatric high frequency oscillatory ventilation (HFOV) management
NEONATAL INDICATIONS PRE HFOV Monitoring CardioVascular Airway Sedation Lung Volume Recruitment Paw PEDIATRIC

-Diffuse Alveolar Disease (Paw > 10) - Diffuse Alveolar Disease (Paw >15) -Early intervention (ELBW) - Air leak syndrome -Air leak syndrome (including PIE) * do not use 3100B for < 35 kg Obtain baseline VS, SpO2/PaO2, and PaCO2/TcPCO2 Insure adequate intravascular volume / C.O. (based on BP, HR, etc) - Verify ETT placement radiographically - Suction (consider in-line catheter) Insure adequate sedation Sedation and muscle relaxation

INITIAL HFOV SETTINGS

Delta P Frequency (HZ)

Bias Flow Inspiratory time FiO2 MANAGEMENT ON HFOV Oxygenation

Optimize lung volume with hand ventilation and inspiratory hold maneuvers as tolerated for DAD. Use caution with air leaks and ELBW patients. High volume strategy (for DAD): High volume strategy (for DAD): 3 - 5 cmH2O > Paw on CMV 5 - 8 cmH2O > Paw on CMV Air leak strategy: Same or 2 - 3 If SpO2 falls rapidly and below 90%, recruit with cmH2O > Paw on CMV Early Intervention: 10 - 14 cmH2O hand ventilation and Paw incrementally For all: if SpO2 falls rapidly and below 90%, Paw incrementally Set Power mid range; adjust to achieve vigorous Full term : 25 cmH2O or greater Pre-term : 16 cmH2O or greater chest vibrations Full term : 12 or 15 Hz Kg 3100A Kg 3100B < 10: 10 - 12 Pre-term / ELBW: 15 Hz 11 - 20: 8 - 10 21 - 40: 6 - 10 35 - 50: 8 - 10 > 40: 5 - 8 > 50: 5 - 8 8 - 15 L/min 15 - 20+ L/min, depending on patient size and required Paw 33 % 33% 1.0 1.0 0.6 with acceptable PaO2/SpO2

High volume strategy: increase Paw by 1-2 cmH2O until FiO2

Early intervention: adjust Paw to maintain FiO2 .30, SpO2 88-92% Air leak strategy: tolerate FiO2 .8 - 1.0 (especially for first 12 - 24 ) to minimize Paw while achieving acceptable PaO2 / SpO2. Very difficult to achieve with pediatric patients Adjust Delta P: 2 - 5 cmH20 to achieve PaCO2 change of 3 - 5 mmHg; > 5 cmH2O to achieve PaCO2 change of 5 - 10 mmHg Hz: decrease only if PaCO2 refractory to changes in Delta P Obtain 1 - 2 hours post-initiation, as often as Q 6-8 hours until stable, then daily and after significant settings changes (e.g. multiple Paw changes). Evaluate for lung expansion: 8-9 ribs optimal. Limit as much as possible, esp. during initial 24 hours. Consider for acute or progressive increase in PaCO2. Perform recruitment maneuvers as tol incrementally, as above; spontaneous breathing incrementally while maintaining acceptable may augment Ve PaCO2 in 1-2 cmH2O increments to 15 - 20 cmH2O and in 1-2 cmH2O increments good recovery post suctioning; may see "plateau" Full/Pre-term: to CMV when 10 -12 VLBW: CPAP with Paw 10, weight gain, and absence of As&Bs

CO2 elimination CXR Suctioning WEANING / DISCONTINUATION Delta P Paw

References Butler WJ, Bohn DJ, Bryan AC, Froese AB. Ventilation by high-frequency oscillation in humans. Anesth Analg 1980; 59:577-84. Slutsky AS, Tremblay LN. Multiple system organ failure. Is mechanical ventilation a contributing factor? Am J Respir Crit Care Med 1998; 157:1721-5. Doctor A, Arnold JH. Mechanical Support of Acute Lung Injury: Options for Strategic Ventilation. New Horizons 1999; 7:359-373. McCulloch PR, Forkert PG, Froese AB. Lung volume maintenance prevents lung injury during high frequency oscillatory ventilation in surfactant-deficient rabbits. Am Rev Respir Dis 1988; 137:1185-92. Priebe GP, Arnold JH. High-frequency oscillatory ventilation in pediatric patients. Respir Care Clin N Am 2001; 7:63345. Chang HK. Mechanisms of gas transport during ventilation by high-frequency oscillation. J Appl Physiol 1984; 56:55363. Arnold JH. High-frequency ventilation in the pediatric intensive care unit. Pediatr Crit Care Med 2000; 1:93-9. Arnold JH, Hanson JH, Toro-Figuero LO, Gutierrez J, Berens RJ, Anglin DL. Prospective, randomized comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure. Crit Care Med 1994; 22:1530-9. Arnold JH, Truog RD, Thompson JE, Fackler JC. High-frequency oscillatory ventilation in pediatric respiratory failure. Crit Care Med 1993; 21:272-8. Courtney SE, Durand DJ, Asselin JM, Hudak ML, Aschner JL, Shoemaker CT. High-frequency oscillatory ventilation versus conventional mechanical ventilation for very-low-birth-weight infants. N Engl J Med 2002; 347:643-52. Johnson AH, Peacock JL, Greenough A, et al. High-frequency oscillatory ventilation for the prevention of chronic lung disease of prematurity. N Engl J Med 2002; 347:633-42.