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Respiratory Care offers clinical reports called "Critical Care Review" also known as a "CCR." These reports review current applications and economics of using high frequency oscillatory ventilation and specific strategies to managing patients. The authors are respected neonatologists and respiratory therapists known in the medical field.
Each report is summarized below. Click click on the link to download the complete Critical Care Review in PDF file format.
Thank you for your interest in high frequency ventilation.
Clinical Management Strategies for Adult Patients
Early Intervention in Respiratory Distress Syndrome
Clinical Management Strategies
HFOV Charges and Reimbursement: Practices and Experience
Pathophysiology of Premature Lung
Disease Specific Clinical Management Stategies
Managing Hemodynamics During High Frequency Oscillatory Ventilation
Transcutaneous Blood Gas Monitoring: A New Direction
High Frequency Oscillatory Ventilation in the Management of Severe Oxygenation Dysfunction During Orthotopic Liver Transplantation
Stephen Derdak, D.O Pulmonary/Critical Care Medicine
PDF 734 kb
With increased understanding
of the physiology of lung recruitment and the adverse consequences
of ventilator induced lung injury (VILI) it has been hoped
that improved ventilator strategies will reduce the morbidity
and mortality of this common cause of respiratory failure
(1). The NIH ARDS network clinical trial recently reported
that a conventional ventilator strategy employing a low tidal
volume "lung protective" approach [tidal volumes
(TV) < 6 ml /kg ideal body weight, inspiratory plateau pressures
(Pplat) < 30 cm H2O] reduced absolute mortality 9% compared
with a larger tidal volume (12 ml/kg) strategy (2). Unfortunately,
in practice, many critically ill patients with ARDS are unable
to achieve oxygenation goals using conventional protective
lung approaches (arbitrarily defined as FiO2 <= 60% with
Pplat <= 30 cmH2O) and the mortality from ARDS remains
unacceptably high. In view of the successful use of high frequency
oscillatory ventilation (HFOV) in neonatal and pediatric acute
respiratory failure syndromes in the 1980's and early 1990's
we became interested in the potential application of this
ventilatory mode for adults with severe ARDS. The optimal
specific techniques of using HFOV in large patients are continuing
to evolve and as with all interventions in critical care,
frequent reassessment of the patient and modification of therapeutic
strategies as the patient's condition changes is essential.
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Stephen Minton, MD, Dale Gerstmann, MD, and Ronald Stoddard, MD
PDF 1973 kb
HFOV is an important
tool in the management of neonates with respiratory distress
and is effective in breaking the continuum of pulmonary injury
sequence. There is a definite learning curve to the safe introduction
of high frequency oscillatory ventilation (HFOV). As with any
new technology, there is an ongoing process of determining optimum
ventilation strategies for clinical management of neonates with
varying types of respiratory failure. In the infant with Respiratory
Distress Syndrome, early use of HFOV with a strategy to achieve
effective, i.e. "optimal" lung recruitment, in combination
with exogenous surfactant administration, may be the best treatment
combination currently available.
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Reese H. Clark, MD and Donald M. Null, MD
PDF 1014 kb
This is a summary
of HFO strategies we use in the management of neonates. As with
any new technology, the definition of optimal is dynamic and
many issues remain to be resolved. Our goal is to communicate
on approach. The safe introduction of HFO requires careful education
of all those involved with its application. This includes, but
is not limited to, nurses, respiratory therapists, physicians
and ECMO specialists. We would like to emphasize all the complications
seen during CMV can be seen on HFO. Hospital inservices reduce
the learning curve’s effect on these complications. While
adjusting this HFO is simple, defining optimal lung volume and
patient specific ventilatory strategies can be difficult. We
believe that HFO is an important adjunct to CMV in the management
of neonates with respiratory failure.
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Tom Bachman
PDF 1652 kb
Since its availability
in the late 1960’s, mechanical ventilation has led to dramatic
improvements in treating infants with hyaline membrane disease
(HMD). However, in today’s economic environment, with each
technological step taken, comes the justification of costs against
the reimbursement attainable. High frequency oscillatory ventilation
(HFOV) is one of those technologies whose charge and reimbursement
has not been systematically reviewed. The bottom line is that
whether you are seizing declining opportunities for reimbursement
enhancement or positioning yourself for capitated care, HFOV
seems to fit.
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Dale Gerstmann, MD, Stephen Minton, MD and Ronald Stoddard, MD
PDF 1709 kb
In the premature infant
who develops pulmonary disease current perspectives consider
each clinical diagnosis encountered as a separate entity. These
familiar diagnoses include Respiratory Distress Syndrome (Hyaline
Membrane Disease), Pulmonary Interstitial Emphysema, Gross Airleak,
Oxygen Toxicity and Chronic Lung Disease (Bronchopulmonary Dysplasia).
Exploration of current information on the development of pulmonary
injury in the surfactant deficient premature infant will lay
the ground work to develop rational treatment strategies for
the use of new ventilator devices, such as high frequency oscillatory
ventilation. Though the exact extent of pathologic injury is
difficult to assess in the clinical setting, use of high frequency
oscillation appears to be able to interrupt the progress of
injury when used with a treatment strategy which emphasizes
maintenance of recruited lung volume and elimination of the
barotrauma associated with tidal volume ventilation.
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Donald Null, MD and Noah Perlman, BS, RRT ~ 1994
PDF 5867 kb
Management of the
patient requiring high frequency oscillatory ventilation is
an art, based on a few simple principles. These basic principles
will lead the clinician to choices which are primarily related
to the pulmonary pathophysiology of the underlying disease.
These guidelines for managing newborns on HFOV represent experience
gained from many ears with this technology. While HFOV seems
to produce uniformly predictable outcomes by following the steps
outlined, each infant and their disease process must be evaluated
individually and the treatment strategy tailored to that particular
patient for successful integration of high frequency ventilation
into their care.
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Stephen Minton, MD
PDF 1171 kb
There
is an inextricable link between hemodynamic characteristics
and response to ventilation settings. Therefore, a careful
evaluation of cardiovascular function in critically ill
patients with pulmonary disease is an important aspect of their
ventilatory management. It is also important to understand
and utilize those tools and measurements that will enhance our
understanding of these inter-relationships. Some of the
specific areas addressed in this Critical Care Review are Clinical
Cardiovascular Monitoring, Pulmonary Artery Occlusion, Oxygen
Delivery, Oxygen Extraction, Cardiac Output in Pediatric Patients,
Left and Right Ventricular Performance, and Hemodynamics in
High Frequency Oscillatory Ventilation.
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Dale Nelson
Advances
in Transcutaneous Monitor technology have now brought the often
cumbersome and time consuming fuctions associated with membrane
changes, recalibration, and sensor failures to a new level of
simplicity and reliability. A variety of innovative monitor
and sensor features have been developed and incorporated in
the SensorMedics MicroGas 7650 Transcutaneous Monitor.
Although the analysis of arterial blood samples is considered the most accurate method
for determining blood gas concentrations, such information reflects
data that is only relevant to the patient's status at the moment
of the sampling. As a result, changes in patient status
in between sampling may go unnoticed. Since critically
ill patients often experience rapid changes in blood gas concentrations,
continuous monitoring of oxygen and carbon dioxide becomes essential
for proper patient care.
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Justin M Burns, William S Miles, Lon Eskind, Toan Huynh, David Jacobs,
Ronald Sing, Surgery, Carolinas Medical Center, Charlotte, NC; Joe Hylton,
Tom Nelson, Respiratory Therapy, Carolinas Medical Center, Charlotte, NC
High Frequency Oscillatory Ventilation (HFOV) has been successfully utilized
in the management of patients with severe oxygenation dysfunction failing conventional
lung protective strategies. Patients on HFOV may require complex
operative procedures, though some believe that the chest wiggle is an obstacle.
We present our experience in the management of a patient with severe oxygenation
dysfunction during orthotopic liver transplantation. A 51 year old male with
end stage hepatic failure presented for orthotopic liver transplantation (OLT).
On post-operative day 3 he developed hepatic failure from primary non-function.
Adult respiratory distress syndrome (ARDS) developed and despite conventional
lung protective strategies he required HFOV for worsening pulmonary
dysfunction. The patient could not be successfully weaned to conventional ventilation
at the time of a second OLT, subsequently; he was transported to the
operating room on HFOV and underwent a six hour emergency OLT. During
the procedure, a median sternotomy was performed for a complication from central
line placement. The settings on HFOV for the procedure: mean airway pressure
of 30 cmH2O, Hertz of 4, power of 6, inspiratory time of 50% and FI02
of 100%. The patients Pa02/FI02 ratio improved from 110 to 426 and there
were no procedural complications related to HFOV identified by the operating
surgeons. The chest wiggle had no effect on technical precision during the multiple
anastamoses. The patient was transported back to the ICU on HFOV where
his ARDS stabilized. He was successfully weaned to conventional ventilation 3
days later. Unfortunately, the patient succumbed to fulminant hepatic failure
several days later. We believe, even in patients requiring complex operative procedures,
HFOV can be utilized successfully to manage severe oxygenation dysfunction.
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