HFOV – Adult Case Study

HFOV Case Study - Admission

• 46 yo unrestrained female MVA• Fractures

– Rt radial, ulna, fibula– Lt ankle

• RML contusion• CT head and c-spine negative• Pt c/o left chest pain and sedated with

morphine and diprivan• VSS

Admission

HFOV Case Study

• Pt transported to OR for fx repair – VSS

• 24 hours later pt developed respiratory distress

• CXR revealed diffuse patchy infiltrates

ABG’sDate 4/17TimeFiO2

Mode NRB RateVolumeMAPAMPPIPPEEPpH 7.38PaCO2 36

PaO2 68

HCO3- 21SaO2 92

TcCO2

ABG’sDate 4/17 4/19Time 0233FiO2

Mode NRB NRB RateVolumeMAPAMPPIPPEEPpH 7.38 7.38PaCO2 36 38

PaO2 68 49

HCO3- 21 22SaO2 92 82

TcCO2

HFOV Case Study

• Pt placed on 1.0 mask CPAP +10• Pt increasingly agitated, SOB,

use of accessory muscles• Pt subsequently intubated

– 1.0/AC/650/14 (no PEEP)– SaO2 78%

• Pt sedated and paralyzed• PEEP 10 cmH2O

ABG’sDate 4/17 4/19 4/19Time 0233 1000FiO2 1.0Mode NRB NRB A/CRate 14Volume 650MAPAMPPIPPEEP 10pH 7.38 7.38 7.27PaCO2 36 38 44

PaO2 68 49 80

HCO3- 21 22 20SaO2 92 82 93

TcCO2

ABG’sDate 4/17 4/19 4/19 4/21Time 0233 1000 1100FiO2 1.0 1.0Mode NRB NRB A/C A/CRate 14 18Volume 650 650MAPAMPPIPPEEP 10 8pH 7.38 7.38 7.27 7.43PaCO2 36 38 44 33

PaO2 68 49 80 101

HCO3- 21 22 20 22SaO2 92 82 93 97

TcCO2

HFOV Case Study

• Although ABG’s improved, pt became increasingly agitated – RR 30’s– High pressure limit– BP, HR – SaO2 40’s

Pre HFOV – 4/21 – 11:00 hrs

HFOV Case Study

• Pt transitioned to HFOV – MAP 28, Hz 5, Amp 70, I time 33%, FiO2

1.0

– Pt paralyzed and sedated, TcCO2 76-78

– ABG 7.13/87/159– Amp 86, dopamine and sedation

weaned– ABG 7.21/65/116

– FiO2 .70, Amp 98

– ABG 7.33/50/101

ABG’sDate 4/17 4/19 4/19 4/21 4/21Time 0233 1000 1100 1200FiO2 1.0 1.0 1.0Mode NRB NRB A/C A/C HFOVRate 14 18 5HzVolume 650 650MAP 28AMP 70PIPPEEP 10 8pH 7.38 7.38 7.27 7.43 7.13PaCO2 36 38 44 33 87

PaO2 68 49 80 101 159

HCO3- 21 22 20 22 28SaO2 92 82 93 97 98

TcCO2 77

ABG’sDate 4/17 4/19 4/19 4/21 4/21 4/21Time 0233 1000 1100 1200 1430FiO2 1.0 1.0 1.0 0.7Mode NRB NRB A/C A/C HFOV HFOVRate 14 18 5Hz 5HzVolume 650 650MAP 28 28AMP 70 86PIPPEEP 10 8pH 7.38 7.38 7.27 7.43 7.13 7.23PaCO2 36 38 44 33 87 65

PaO2 68 49 80 101 159 108

HCO3- 21 22 20 22 28 27SaO2 92 82 93 97 98 96

TcCO2 77

ABG’sDate 4/17 4/19 4/19 4/21 4/21 4/21 4/21Time 0233 1000 1100 1200 1430 1935FiO2 1.0 1.0 1.0 0.7 0.5Mode NRB NRB A/C A/C HFOV HFOV HFOVRate 14 18 5Hz 5Hz 5HzVolume 650 650MAP 28 28 28AMP 70 86 98PIPPEEP 10 8pH 7.38 7.38 7.27 7.43 7.13 7.23 7.33PaCO2 36 38 44 33 87 65 50

PaO2 68 49 80 101 159 108 101

HCO3- 21 22 20 22 28 27 26SaO2 92 82 93 97 98 96 96

TcCO2 77

ABG’sDate 4/17 4/19 4/19 4/21 4/21 4/21 4/21 4/22Time 0233 1000 1100 1200 1430 1935FiO2 1.0 1.0 1.0 0.7 0.5 0.4Mode NRB NRB A/C A/C HFOV HFOV HFOV HFOVRate 14 18 5Hz 5Hz 5Hz 5HzVolume 650 650MAP 28 28 28 25AMP 70 86 98 98PIPPEEP 10 8pH 7.38 7.38 7.27 7.43 7.13 7.23 7.33 7.35PaCO2 36 38 44 33 87 65 50 59

PaO2 68 49 80 101 159 108 101 91

HCO3- 21 22 20 22 28 27 26 32SaO2 92 82 93 97 98 96 96 96

TcCO2 77

HFOV – 4/22 – 04:39 hrs

ABG’sDate 4/19 4/19 4/21 4/21 4/21 4/21 4/22 4/23Time 0233 1000 1100 1200 1430 1935FiO2 1.0 1.0 1.0 0.7 0.5 0.4 0.4Mode NRB A/C A/C HFOV HFOV HFOV HFOV HFOVRate 14 18 5Hz 5Hz 5Hz 5Hz 4HzVolume 650 650MAP 28 28 28 25 22AMP 70 86 98 98 98PIPPEEP 10 8pH 7.38 7.27 7.43 7.13 7.23 7.33 7.35 7.4PaCO2 38 44 33 87 65 50 59 45

PaO2 49 80 101 159 108 101 91 82

HCO3- 22 20 22 28 27 26 32 27SaO2 82 93 97 98 96 96 96 95

TcCO2 77

HFOV – 4/23 – 10:26 hrs

Transition to CMV

• PCV – PIP = 30cmH2O

– Vt = 680 (wt 75kg)

– FiO2 = .60

– PEEP = 5cmH2O

• ABG – 7.47/44/62

• PCV– PIP 20cmH2O, PEEP 8cmH2O

ABG’sDate 4/19 4/21 4/21 4/21 4/21 4/22 4/23 4/24Time 1000 1100 1200 1430 1935FiO2 1.0 1.0 1.0 0.7 0.5 0.4 0.4 0.6Mode A/C A/C HFOV HFOV HFOV HFOV HFOV PCVRate 14 18 5Hz 5Hz 5Hz 5Hz 4Hz 18Volume 650 650 680MAP 28 28 28 25 22AMP 70 86 98 98 98PIP 30PEEP 10 8 5pH 7.27 7.43 7.13 7.23 7.33 7.35 7.4 7.47PaCO2 44 33 87 65 50 59 45 44

PaO2 80 101 159 108 101 91 82 62

HCO3- 20 22 28 27 26 32 27 32SaO2 93 97 98 96 96 96 95 91

TcCO2 77

PCV – 4/24 – 07:58 hrs

ABG’sDate 4/21 4/21 4/21 4/21 4/22 4/23 4/24 4/24Time 1100 1200 1430 1935FiO2 1.0 1.0 0.7 0.5 0.4 0.4 0.6 0.5Mode A/C HFOV HFOV HFOV HFOV HFOV PCV PCVRate 18 5Hz 5Hz 5Hz 5Hz 4Hz 18 12Volume 650 680MAP 28 28 28 25 22AMP 70 86 98 98 98PIP 30 20PEEP 8 5 8pH 7.43 7.13 7.23 7.33 7.35 7.4 7.47 7.46PaCO2 33 87 65 50 59 45 44 45

PaO2 101 159 108 101 91 82 62 163

HCO3- 22 28 27 26 32 27 32 31SaO2 97 98 96 96 96 95 91 99

TcCO2 77

ABG’sDate 4/21 4/21 4/21 4/22 4/23 4/24 4/24 4/29Time 1200 1430 1935FiO2 1.0 0.7 0.5 0.4 0.4 0.6 0.5 0.4Mode HFOV HFOV HFOV HFOV HFOV PCV PCV PSVRate 5Hz 5Hz 5Hz 5Hz 4Hz 18 12Volume 680MAP 28 28 28 25 22AMP 70 86 98 98 98PIP 30 20 5PEEP 5 8 5pH 7.13 7.23 7.33 7.35 7.4 7.47 7.46 7.49PaCO2 87 65 50 59 45 44 45 33

PaO2 159 108 101 91 82 62 163 150

HCO3- 28 27 26 32 27 32 31 24SaO2 98 96 96 96 95 91 99 99

TcCO2 77

HFOV Case Study

• Pt extubated on 4/29 and placed on 40% HHM, bronchodilator therapy and incentive spirometry

• Pt discharged to rehab facility on 5/2