1

The Role of the VDR Ventilator

OBJECTIVESOBJECTIVES

• Describe how the VDR was chosen for Legacy Emanuel Hospital and it’s use in various ICU’s

• Review the HFPV wave forms

• Describe the potential advantages of the Percussive form of High Frequency Ventilation

• Discuss ECMO applications

How did it’s use expand ?

•“We” - 75 Dedicated Emanuel Respiratory Therapists

–Respiratory Specialists at Legacy, Jennifer Ulrich, Jeff Heltborg, Denny Gish

–Respiratory Care Medical Director, Dr. Bernie Sperley

Who Chose the VDR ?Oregon Burn Center Medical Director, Dr. Phil Parsley

Contributors

• National Burn Centers– LAC – USC – Via Christi– Santa Clara– Lehigh Valley– Mercy St Johns– Coxhealth– Memorial Hermann – Texas Medical Center

• But, Most of all

Two Presidents – Two Presidential Medals

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Where the Percussionaire Devices Originated

What is a VDR?

• -High Frequency Percussive Ventilation (HFPV) is a hybrid form of high frequency ventilation.

• It is a combination of convective style ventilation and percussive high frequency linked together.

VDR waveform• Capnography

– Muscle relaxants (curare cleft)

Translation

• Dr Bird says -

“This concept of pneumatic diffusive / convective protocols is not related to high frequency vibration, jet insufflation or electronically controlled crank or magnetically servoed dynamic oscillators.”

• Denny says –“High Frequency Percussive

Ventilations isn’t like the other types of High Frequency Ventilation”

High Frequency Ventilation

• Oscillator – 3100A & B

• Jet – Bunnell

• Flow Interrupter - VDR

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ALL LISTED ORDERS ARE IN EFFECT UNLESS CROSSED OUT. EXCEPTIONS: ORDERS PRECEDED BY A BOX () REQUIRE A () TO INITIATE; ORDERS WITH BLANKS REQUIRE ADDITIONAL INFORMATION TO INITIATE.

ORDERS: ANOTHER BRAND OF GENERICALLY EQUIVALENT OR APPROVED THERAPEUTICALLY EQUIVALENT PRODUCT MAY BE ADMINISTERED UNLESS CHECKED

VDR Volumetric Diffusive Respirator

PRE-PRINTED ORDERS USE BALL POINT PEN, PRESS FIRMLY

Date: TIME:

Physician or Credentialed Provider’s signature: All Pre-Printed Orders must have a physician/credentialed provider’s signature to initiate.

Patient Selection: to previous level 1. It has been recommended that a leak around the endotracheal tube cuff be heard; however, this can

complicate CO2 control and may not be indicated with many patients.

2. Use of this device should be limited to patients with airway burn injury, excessive secretions or very narrowed airways.

Starting Settings:

Use the following settings when initiating VDR therapy.

Control Adult Pediatric

Operating Pressure 40-50psi 30-40psi

Pulsitile flowrate (PIP) 25 cm H20 25 cm H20

Inspiratory Time : Expiratory Time (seconds) IT=2sec:ET=2 sec IT=1sec:ET=1sec

Rate (product of I and E Time) 15 30

Pulse i:e Ratio set at 11 – routinely kept at this setting

Demand PEEP/CPAP Setting to 0-2 cmH20 (approx. 9 on knob)

Oscillatory PEEP setting for total PEEP of 10cmH2O. Measure at the top of the waveform during expiratory phase

Pulse Frequency at 500 breaths per minute

FIO2 – Begin at current FIO2 requirement or 100% if unknown

VDR Management

______Keep ABG’s in ordered range utilizing setting changes listed below.

Desired Blood Gas Change

Setting Change

Increase PaO2/SpO2 and decrease PCO2

Increase PIP with Pulsatile Flowrate Control

Increase Oxygenation if CO2 is in range

Increase FIO2 Increase Oscillatory CPAP/PEEP in 2cmH20 increments (maximum 20cmH20) Increase PIP with Pulsatile Flowrate Control

Decrease CO2 only Increase PIP with Pulsatile Flowrate Control If PIP is >50 cmH2O and Oxygenation in range, decrease Pulse Frequency

from 500 to 350. Do this with great caution as it may cause airway damage. If FIO2 requirement is low and CPAP level is high, patient may be

overdistended. Decrease Oscillatory CPAP levels 2cmH2O/hour. Monitor SpO2 for worsening oxygenation, and return to previous level CPAP.

Raise C02 with low PIP Decrease delta P by 1) lowering Pulsatile Flowrate if FIO2 requirement is <40% or 2) raising the oscillatory CPAP if FIO2 requirement is >40%

PEEP Level Displayed

Actual PEEP

1. Cuff leak – introduces a variable leak into the system, if adjusted appropriately pressure(s) at the distal end of the Endotracheal tube will be about 1/3 less than at the airway. Although it is important that a leak be present, it is not mandatory; but secretions m ay be more likely tocollect and dry at the distal end of the endotracheal tube and potentially, obstruct the airway. Having the cuff partially deflated brings the secretions into the patients m outh where they may be removed by oral suctioning. A cuff leak may com plicate CO2 managem ent by allowing varying amounts of CO2 to be removed.

2. Air trapping – The VDR is a high frequency ventilator with a passive expiratory phase, at 500 breaths per minute (8.3 Hz), it can be expected to cause a degree of air trapping. At higher frequencies, more air trapping will occur. It is recomm ended that the frequency be kept at 500 in m ost cases. Lowering the frequency results in larger, high frequency, tidal volume breaths and increased ventilation, but may cause airway damage if applied for extended periods of time.

3. PEEP- The PEEP level displayed is actually the peak pressure of the high frequency ventilation breaths generated during the expiratory phase. Actual PEEP level is approxim ately ½ the displayed PEEP level

4. Mechanical Deadspace – W ith a continuous leak around the endotracheal tube, mechanical deadspace (i.e. adapters, flex tubes) does not present a problem ; however when the leak is removed, m echanical deadspace should be assessed.

5. Monitoring – EtCO2 is not accurately reflected when there is a leak around the endotracheal tube or spontaneous breathing is allowed. A BG’s will be the standard method to determine CO2 levels.

6. The VDR circuit – Because the VDR introduces large am ounts of dry gas flow at the airway during inspiration, it is essential to maximize humidification. The nebulizer line (yellow) adapts to the hum idifier and then tees in to the circuit directly at the patient airway and m ust be kept running at all tim es. The second humidifer should have the accessory flow (green) adapted to the chamber and the other end attached to the distal end of the phasitron. Care m ust be taken to keep the pressure sensing line (Red tubing ) facing upw ard and frequent (q6) change of the in-line filter, to keep water out of the line. Suspending the Phasitron from above with the red tubing up is an excellent way of securing the device for clinical use.

7. Amplitude – Begin at 20-30 cm H20 on Proximal Airway Pressure manom eter. This will register approxim ately 30-45 cm H20 on the M onitron. Airway pressures on the Proximal Airway Pressure manometer are indicative of the pressures delivered to the distal airway (also affected by cuff leak).

8. Convective Pressure Rise – standard to leave off (turned fully clockwise). M ay use convective pressure rise for recruitment technique during initial settings. Care should be taken if percussive ventilation is an issue, as use of convective pressure rise will cause a decrease in the oscillatory effect.

12/2007

A Sliding Venturi:•“floating” exhalation valve•Entrains during inspiratory

•Entrains up to 1:5•Pneumatic clutch –“feels” backpressure

•Open to ambient during expiratory•Flow to pressure / pressure to flow converter•7ms transition penalty

•Allows theoretical rates up to 7200 bpm

The Phasitron®; The patient interface

Accelerating Laminar Flow

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Inspired gas streams into the airways with high velocity, but low pressure.

The train of tiny tidal volumes moves high pO2 gas toward the alveoli, while CO2 is compressed against airway walls.

Patented Phasitron and Gas Flow

CO

2

It streams down the airways, splitting at bifurcations, always seeking the path of least

resistance in the centerof the airways.

1. Airways stay open at low Paw.

2. Exhaled gas swirls out along airway walls, facilitating mucociliary and CO2 clearance.

Patented Phasitron and Gas FlowIPV for Post OHS

Post OHS Patients

• Start IPV treatment if:– Patient has not been extubated

within 48 hrs. of admit to ICU (unless patient is already on a VDR)

- or -• Patient has Hx of

RAD/COPD with home nebulizer use.

LEH IPV Applications Before IPV

_______

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After One 20min. IPV Rx_______

IPV Legacy Emanuel Hospital VDR Applications

• Thermal Lung Injury• Secretion Management• Airway Restriction• Rescue

– H1N1 and ECMO ventilation– When all others fail

Ventilation Strategy

Anticipated short-term need for ventilatory support or otherwise stable patient with DNI status

Place on conventional ventilation

Does patient improve?

Does pt have non-compliant lungs, ARDS or meet moderate criteria for

ISS?

Is pt on appropriate PEEP, recruitment maneuvers, and/or appropriate fluid / volume support?

Apply combination of optimal PEEP, recruitment maneuvers, and/or

cardiovascular support.

Pt improvement over the past 12 hours? (P/F ratio >200)

Continue with conventional ventilation

Patient improvedP/F ratio over 8-12

hours

Consider APRV, ARDS Network Protocol or VDR

Does the patient have a large volume of secretions, thermal lung injury, wet ARDS, extremely narrowed airways or uncontrolled air leak?

Place on VDR

Place on APRV or ARDS Network

Protocol

Patient improvement over 8-12 hours? (P/F ratio >200)

Continue APRV

Use APRV and check the following - Is patient trapping 70% of airflow? - Is pHigh at a maximum setting? - Have recruitment techniques been applied? - Is cardiac support adequate? - Is there unilateral lung disease?

Patient improvement over 8-12 hours? (P/F ratio >200)

Continue APRV

Consider VDR

Consider Non InvasiveVentilation.

Does patient improve?

Continue NIV

Place on APRV

Continue APRV or ARDS Network protocol

Continue conventional ventilation.

Consider SmartCare mode / Best Practice Bundle to prepare for extubation.

0.0

00.

250.5

00.

751.

00

0 50 100 150 200Analysis time (days)

Conventional ECMO

Kaplan-Meier survival estimates, by allocation

63%

47%

RR 0.6995% CI 0.05 – 0.97

p=0.03

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Adult H1N1 ARDS Ventilator Strategy

Conventional Ventilation with ARDSnet Strategy

See page 3

Consider CT scan: evaluate for reversible issues Consider for Recruitment Maneuvers* Optimize Cardiovascular Status/ Swan-Ganz prn Address anatomical issues: PTX, effusions, etc Evaluate for Proning, Paralytics, Nitric Oxide

*Recruitment Maneuver Must be approved by

physician CPAP 40 cmH2O for 40sec

-OR- eSIGH with PEEP 10cm above LIP

Set PEEP above Lower Inflection Point at end of maneuver

ALI/ARDS Inclusion Criteria: PaO2/FiO2 < 300 (ALI)

PaO2/FiO2 <200 (ARDS) Bilateral Infiltrates No LA Hypertension Acute Onset

Continue APRV

Place on APRV See Page 3 Consider Consultation or

Transfer to Emanuel

Place on HFOV: See page 4 Consider Transfer to Emanuel

Need for Ventilatory Support

Assessment of Patient Improvement: P/F ratio > 200 On FiO2 ? 70% and PEEP ? 12 Meeting ventilation goals with

pH ? 7.25

Consider Direct Initiation of VDR for (VDR is a type of HFOV):

Severe ARDS in pregnant or obese patient

Inhalation Injury Massive Secretions/Lobar

collapse Status Asthmaticus Massive Air Leak

Consider ECMO for inadequate improvement (as above).

Assessment of Patient Improvement: P/F ratio > 200 On FiO2 ? 70% and PEEP ? 12 Meeting ventilation goals with

pH ? 7.25

Consider Trial of Non Invasive Ventilation Bipap with EPAP ? 8 and

FiO2 < 60%

Continue ARDSnet Strategy

Legacy Emanuel Health Center320 bedregional, tertiary referral, University affiliated, not-for-profit

Trauma ProgramAmerican College of Surgeons Level IOregon Health Division Level Iinitiated in 19882770 admissions

Cardiac Programfull spectrum – congenital, coronary, complex aorticpediatric and adult

ECMO programneonatal 1987pediatric 1998adult 1986

T em po ra ry L E H C o n s e n s u s R e sp ira to ry P ro to co l D R A F T 0 0 1 1 0 -1 4 -0 9

N O T E : m a n y a s p e c ts o f th e s e su g g e s te d s te p s a re o p en to d is c u s s io n a n d s ty lis t ic va ria tio n . T h e g o a l s e t fo rth fo r u s is to co n s id e r a d iff ic u lt con f lic t fo r th e m o s t a d va n c ed m o de s o f re s p ira to ry s u p p o rt (A P R V , V D R a n d E C M O ) if th e H 1 N 1 v iru s c a u s e s a s ign if ic a n t a d d it io n to o u r p ra c tic e . IN C L U S IO N C R IT E R IA : A c u te o n se t o f - 1 . P a O 2 /F iO 2 < 3 0 0 (co rre c te d fo r a ltitu d e ) 2 . B ila te ra l (pa tch y , d iffu se , o r h o m o g e n e o u s) in f iltra te s co n s is te n t w ith p u lm o na ry e d e m a 3 . N o c lin ic a l e v id e n ce o f le ft a tr ia l h yp e rte n s io n (n l C V P o r P a w ) I f a ss is te d ve n tila t io n is re q u ire d , in itia te w ith s ta n d a rd m o d e s :

C M V – M M V – P R V C – A C / P S N O T E : W e s h o u ld a vo id m a s k B IP A P a s it is re la tive ly in e ffe c tive , a nd w ith H 1 N 1 is a n in fe c tio n c o n tro l r isk . V E N T IL A T O R S E T -U P 1 . C a lc u la te p re d ic ted b o d y w e ig h t (P B W ) M a le s = 5 0 + 2 .3 [he ig h t ( in ch e s ) - 6 0 ] F e m a le s = 4 5 .5 + 2 .3 [h e ig h t ( in c he s ) -6 0 ] 2 . S e le c t an y ve n tila to r m od e 3 . S e t ve n tila to r se ttin gs to a ch ie ve in it ia l V T = 8 m l/k g P B W 4 . R e d u c e V T b y 1 m l/k g a t in te rva ls ! 2 h o u rs u n til V T = 6 m l/k g P B W . 5 . S e t in it ia l ra te to ap p ro x im a te b a se lin e m in u te ve n tila t ion (n o t > 35 b p m ). 6 . A d ju s t V T a n d R R to a ch ie ve p H a n d p la te a u p re s s u re g o a ls b e low .

P L A T E A U P R E S S U R E G O A L : < 3 0 cm H 2 O C h e ck P p la t (0 .5 se co n d in sp ira to ry p a u se ), a t le a s t q 4 h a nd a fte r e a c h c h a n ge in P E E P o r V T . If P p la t > 3 0 cm H 2 O : d e c re a s e V T b y 1 m l/kg s te p s (m in im um = 4 m l/k g ). If P p la t < 2 5 cm H 2 O a n d V T < 6 m l/k g , in c re a s e V T b y 1 m l/kg u n til P p la t > 2 5 cm H 2 O o r V T = 6 m l/kg . If P p la t < 3 0 a n d b re a th s ta c k in g o r d ys -syn c h ro n y o cc u rs : m a y in c re a se V T in 1 m l/kg in c re m e n ts to 7 o r 8 m l/kg if P p la t re m a in s < 3 0 c m H 2 O .

L e g a c y E m a n u e l M e d ic a l C e n te r E C M O S e rv ic e

V e n tila tio n / P e rfu s io n M a n a g em en t G u id e lin e fo r P a te n ts o n E C M O

P r in c ip le : P a t ie n ts o n E C M O re q u ire e x tra c o rp o re a l su p p o rt o f th e ir res p ira to ry s y s te m . T h e E C M O c irc u it c an g e n e ra lly p ro v id e n e a r fu ll s u p p o rt o f b o th o x y g e n a t io n a n d C O 2 re m o v a l re q u ir e m e n ts . T h e v e n tila to r m u st b e re d u c e d to s a fe le v e ls to re d u c e th e lik e l ih o o d o f v e n t ila to r in d u c e d lu n g in ju ry o n to p o f th e m e c h a n ic a l (a sp ira tio n , in fe c tio n , c o n tu s io n , e tc ) an d a lre a d y p re s e n t in f la m m a to ry in s u lts to th e lu n g . V e n o -v e n o u s E C M O P r a c t ic e :

V e n ti la t io n : T h e V D R v en tila to r w ill b e p re fe re n t ia lly u se d . 1 . In itia l “ res t se t tin g s ” w il l b e :

es ta b lish th e P IP /P h i/u p p er p re ss u re to < 3 0 c m H 2 O . S ta r tin g m e an a irw a y p re ss u re s h o u ld b e < 2 5 c m H 2 O .

es ta b lish th e P E E P /P lo /lo w e r p re s su re to 1 2 c m H 2 O th e d e lta -P o r tid a l p res s u re w ill b e > 1 0 c m H 2 O (p u ls a tile -P E E P ) F iO 2 g o a l sh o u ld b e .5 0

2 . A rec ru i tm e n t m a n e u v e r in th e fo rm o f a co n v e c t iv e p re s su re rise to 4 0 c m H 2 O w ill b e d o n e e v e ry 8 h rs .

3 . T h e re cru itm e n t m a n e u v e r w ill b e te rm in a ted e a r ly fo r w o rs e H R , B P , S a O 2

o r o th e r s ig n s o f d is t re s s .

4 . R e c o rd re s u lts o n th e re c ru itm e n t t ria l s h e e t a n d k ee p o n th e v e n t ila to r c l ip b o a rd .

N o tes :

1 . If th e p a tie n t is re c ru i tin g , d isc u s s w ith a n a tten d in g th e o p tio n s fo r

m a in ta in in g o p e n lu n g u s in g th e a d d i tio n o f a s m a ll c o n v e c tiv e p re ss u re ris e o r a d d itio n a l P E E P . (P re ss u re in c re a se o f 1 0 w ith c o n v ec t iv e p re s su re rise .)

2 . P a tie n ts w ith m o d e ra te o r g re a te r s e c re tio n s m a y im p ro v e w ith a 1 5 m in

“ IP V ” tre a tm e n t o n V D R to a fre q u e n c y o f 1 0 0 -3 0 0 . C o n s u lt w ith a n a t te n d in g fo r o rd e rs .

3 . If o rd e re d , th e s e t re a tm e n ts w ill b e p e rfo rm e d e v e ry 8 h o u rs b e fo re th e

re c ru itm e n t m a n e u v e r .

L egacy E m an u el H o sp ita l E C M O S ervice

T R IA L O F F P ro to co l

R esp o n sib le P a rties : R esp iratory T h erap ists P erfu sio nis ts W W IC U R N s E C M O atten d ing s L IM S atten d in gs B a ck g ro u n d : A s p atien ts begin to reco ve r, d aily assessm ent of p u lm o n ary fun ctio n is necessary . T his m eth od es tab lish es a S A FE , an d S T A N D A R D p ro to co l fo r the ev a lua tion . S election : W h en a p atien t d em on strates an step-u p o f o x yg en satu ratio n from th e P A lin e ox im eter (S v O 2 ) to th e p erip he ral arteria l o x ym ete r (S aO 2 ), they w ill receiv e d a ily T R IA L s O F F . P atien ts w h o are pro fo u n dly h yp o x em ic (S aO 2 < 92 ) o r th ose w ho d o n ot step up fro m S v O 2 to S aO 2 are n o t to be T R IA L O F F ’d P ro ced u re: T h e R R T an d p erfus ion is t m u st be pre sen t. T h e E C M O attend in g m ust b e o n the un it. 1 00 % T ria l: T h e v en tila to r is set to an F iO 2 o f 1 .0 (1 00 % ) o r th e h igh es t F iO 2 tha t d oes no t co m pro m ise flo w . T h e p ressu res w ill b e cho sen to p rov id e ches t rise b y th e E C M O A ttend in g an d th e R T b efore tria l. T h e E C M O circuit is set to 1 l/m flo w w ith n o ch an ge in O 2 co n centra tion . S w eep is a lso d ecreased to 1 l/m . (A C T m u st be > 1 80 ) A ll v ita ls a re m on ito red fo r 1 5 m inu tes . T R IA L O FF is term in ated fo r S aO 2 < 9 2% o r o the r in dica tion s of hem od yn am ic o r resp ira tory ins tab ility. T erm in atio n is m anaged b y res torin g E C M O flow an d sw eep to p re -T R IA L O F F settin gs, an d , a fter th e S aO 2 is back to b aseline, th e v en tila to r is re set to re st settin gs. A fter 15 m in ute s o f T R IA L O F F, d raw a b lo o d g as from th e p atien t’s a rteria l lin e an d ;

If P :F ratio is < 2 00 , retu rn patien t to the ir E C M O “res t se ttings” V D R at 26 -3 0 / 1 2 -1 5 , R R 15 , 40 % or patien t sp ecific “ res t se ttings”. 5 0% T ria l: If P :F ratio is > 2 0 0, th e v enti la tor is set to F iO 2 o f 0 .5 (5 0% ) for ano th er 1 5 m inu tes . A fter 15 m in ute s o f T R IA L O F F, d raw a b lo o d g as from th e p atien t’s a rteria l lin e an d ; retu rn pa tien t to th eir E C M O “rest settin gs” V D R at 26 -3 0 / 1 2 -1 5 , R R 15 , 40 % or patien t sp ecific “ res t se ttings”. A fter the T R IA L O F F, th e atten din g is in fo rm ed and d ata are reco rded (A P P E N D IX A ) .

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Rotoflow console

8

Rotoflow console

pump head

A man suffered from insomnia and dyslexia. He was also an

agnostic. What did he do?

• He stayed up all night wondering if there was a DOG.