HFO is a well debated topic but still man ICU physicians and respiratory therapists seem to be afraid of it and avoid this therapy. If in expert hands and utilized judicially it has saved lives and still has a lot of potential in it nit yet explored. Although this presentation is very long but it is drafted by keeping in ind to explain every thing about high frequency oscillatory ventilator to a beginner.

1. 3/18/2022 1
Muhammad Asim Rana
MBBS, MRCP, FCCP, EDIC, SF-CCM
Department of Critical Care Medicine
King Saud Medical City
Riyadh, Saudi Arabia

2. 3/18/2022 2
Mechanical ventilation is the
cornerstone of supportive care for
acute respiratory failure.
In most patients, adequate gas
exchange can be ensured while more
specific treatments are administered.

3. 3/18/2022 3
Conventional Ventilation, its
limitations & development
of HFV

4. 3/18/2022 4
 High airway pressures,
 Circulatory depression, and
 Pulmonary air leaks.

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 In patients with acute lung injury
(ALI) and ARDS, conventional
mechanical ventilation (CV) may
cause additional lung injury.

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Pressure Volume Curve

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Changing Lung Volume In CV
Paw = Lung Volume

8. 3/18/2022 8
CDP= FRC
CT 1 CT 2
CT 3
Paw = CDP
Continuous
Distending
Pressure

9. 3/18/2022 9
Volume
Pressure
Zone of
Overdistention
“Safe”
Window
Zone of
Derecruitment
and Atelectasis
Injury
Injury
Optimized Lung Volume “Safe Window”
 Overdistension
• Edema fluid
accumulation
• Surfactant degradation
• High oxygen exposure
• Mechanical disruption
 Derecruitment
Atelectasis
• Repeated closure / re-
expansion
• Stimulation
inflammatory response
• Inhibition surfactant
• Local hypoxemia
• Compensatory
overexpansion

10. 3/18/2022 10
 An alternate mode of ventilation may be
instituted in an attempt to provide
adequate gas exchange and limit
ventilator-induced lung injury. Approaches
used in patients with severe lung injury
include:
 Inverse ratio ventilation
 Pressure-limited ventilation
 Airway pressure release ventilation
 Recruitment maneuvers
 Prone positioning
 High frequency ventilation
 Nitric oxide
 Extracorporeal CO2 removal and ECMO

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 These adverse effects stimulated the
development of high-frequency
ventilation (HFV).
(There was great enthusiasm for HFV
during its early development in the
1970s and 1980s).

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However, the initial enthusiasm for
HFV waned as clinical studies failed
to demonstrate important
advantages over Conventional
Ventilation.

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There is now renewed interest in HFV
because of increasing evidence that
 (1) CV may contribute to lung injury
in patients with acute lung injury
(ALI) and ARDS
 (2) modifications of mechanical
ventilation techniques may prevent
or reduce lung injury and improve
clinical outcomes in these patients.

14. 3/18/2022 14
Potential role of HFV
Achieving adequate gas exchange
while protecting the lung against
further injury in patients with
ALI/ARDS.
TI - Use of ultrahigh frequency ventilation in patients with
ARDS. A preliminary report.
AU - Gluck E; Heard S; Patel C; Mohr J; Calkins J; Fink MP;
Landow L
SO - Chest 1993 May;103(5):1413-20.

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Introduction
 HFV is a mode of mechanical
ventilation that uses rapid
respiratory rates (respiratory rate [f]
more than four times the normal
rate) and small Vts.

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Variations of HFV
These may be broadly classified as
1. high-frequency positive pressure
ventilation (HFPPV),
2. high-frequency jet ventilation
(HFJV), and
3. high-frequency oscillation (HFO).

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HFPPV
 HFPPV was introduced by Oberg and
Sjostrand in 1969.
 HFPPV delivers small Vts (approximately 3
to 4 mL/kg) of conditioned gas at high
flow rates (175 to 250 L/min) and
frequency (f, 60 to 100 breaths/min).

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 The precise Vt is difficult to measure.
 Expiration is passive and depends on
lung and chest wall elastic recoil.
 Thus, with high f, there is a risk of
gas trapping with over distention of
some lung regions and adverse
circulatory effects.

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HFJV
 Sanders introduced
HFJV in 1967 to
facilitate gas
exchange during
rigid bronchoscopy.
 In HFJV, gas under
high pressure (15
to 50 lb per square
inch)is introduced
through a small-
bore cannula or
aperture(14 to 18
gauge) into the
upper or middle
portion of the
endotracheal tube.

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 Pneumatic, fluid, or
solenoid valves
control the
intermittent
delivery of the gas
jets.
 Aerosolized saline
solution in the
inspiratory circuit is
used to humidify
the inspired air.
 Some additional gas
is entrained during
inspiration from a
side port in the
circuit.

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 This form of HFV generally delivers a
Vt of 2 to 5 mL/kg at a f of 100 to
200 breaths/min.
 The jet pressure (which determines
the velocity of air jets) and the
duration of the inspiratory jet (and,
thus, the inspiratory/expiratory ratio
[I/E]) are controlled by the operator.

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 Together, the jet velocity and
duration determine the volume of
entrained gas.
 Thus, the Vt is directly proportional
to the jet pressure and I/E.

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 As with HFPPV, expiration is passive.
 Thus, HFJV may cause air trapping.

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High Frequency Oscillation
 Lunkenheimer et al introduced HFO
in 1972.
 HFO uses reciprocating pumps or
diaphragms.
 Thus, in contrast to HFPPV and HFJV,
both expiration and inspiration are
active processes during HFO.

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 HFO Vts are approximately 1 to 3
mL/kg at fs up to 2,400 breaths/min.
 The operator sets the f, the I/E
(typically approximately 1:2), driving
pressure, and mean airway pressure
(MAP).

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 The oscillatory Vts are directly
related to driving pressures.
 In contrast, Vts are inversely related
to frequency.
 The inspiratory bias flow of air into
the airway circuit is adjusted to
achieve the desired MAP

27. 3/18/2022 27

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Frequency controls the time allowed
(distance) for the piston to move.
Therefore, the lower the frequency , the
greater the volume displaced, and the
higher the frequency , the smaller the
volume displaced.

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CDP=FRC=
Oxygenation
HFOV Principle:
+ + + + +
- - - - -
Amplitude
Delta P =
Tv =
Ventilation
I
E
HFOV = CPAP with a wiggle !

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Pressure transmission CMV / HFOV
 Distal amplitude
measurements with
alveolar capsules in
animals, demonstrate it
to be greatly reduced
or “attenuated” as the
pressure traverses
through the airways.
 Due to the attenuation
of the pressure wave,
by the time it reaches
the alveolar region, it is
reduced down to .1 - 5
cmH2O.
Gerstman et al

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Pressure transmission HFOV
P
T
proximal
trachea
alveoli

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Advantages of HFO
1. There is no gas entrainment or
decompression of gas jets in the airway,
allowing better humidification and warming
of inspired air.
2. The risks of airway obstruction from
desiccated airway secretions is lower.
3. In addition, active expiration permits better
control of lung volumes than with HFPPV
and HFJV, decreasing the risk of air
trapping, overdistention of airspaces, and
circulatory depression.
4. Lower I/Es (1:2 or 1:3) reduce the risk of
air trapping.

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Selected Features of CV & HFV

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Gas Transport During
HFV

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1.Direct Bulk Flow
 Some alveoli situated
in the proximal
tracheobronchial tree
receive a direct flow
of inspired air. This
leads to gas
exchange by
traditional
mechanisms of
convective or bulk
flow.

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2.Longitudinal (Taylor) Dispersion
 Turbulent eddies and
secondary swirling
motions occur when
convective flow is
superimposed on
diffusion. Some fresh
gas may mix with
gas from alveoli,
increasing the
amount of gas
exchange that would
occur from simple
bulk flow.

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3.Pendeluft
 Units can mutually
exchange gas, an
effect known as
pendeluft. By way of
this mechanism even
very small fresh-gas
volumes can reach a
large number of
alveoli and regions

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4.Asymmetric Velocity Profiles
 The velocity profile of air
moving through an airway
under laminar flow
conditions is parabolic.
 Air closest to the
tracheobronchial wall has a
lower velocity than air in the
center of the airway lumen.
 This parabolic velocity
profile is usually more
pronounced during the
inspiratory phase of
respiration because of
differences in flow rates.

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 With repeated respiratory cycles, gas in the
center of the airway lumen advances further
into the lung while gas on the margin (close to
the airway wall) moves out toward the mouth.

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 During inspiration, the
high frequency pulse
creates a bullet shaped
profile with the central
molecules moving
further down the air way
than those molecules
found on the periphery
of the airway.
 On exhalation, the
velocity profile is blunted
so that at the completion
of each return , the
central molecules remain
further down the airway
and the peripheral
molecules move towards
the mouth of the airway.

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5.Cardiogenic Mixing
 Mechanical
agitation from the
contracting heart
contributes to gas
mixing, especially
in peripheral lung
units in close
proximity to the
heart.

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6.Molecular Diffusion
 As in other modes
of ventilation, this
mechanism may
play an important
role in mixing of air
in the smallest
bronchioles and
alveoli, near the
alveolocapillary
membranes.

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ALI/ARDS

45. 3/18/2022 45

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 Chest Radiographs & CT Images

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 Patients with ALI/ARDS frequently
develop acute respiratory failure.
 Physiologic dead space typically is
also elevated, which increases the
minute ventilation required to
maintain normal arterial Paco2 and
pH.
TI - High-frequency percussive ventilation improves oxygenation in
trauma patients with acute respiratory distress syndrome: a
retrospective review.AU - Eastman A; Holland D; Higgins J; Smith B;
Delagarza J; Olson C; Brakenridge S; Foteh K; Friese RSO - Am J
Surg. 2006 Aug;192(2):191-5.

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Our Rescue here is
Mechanical Ventilation
BUT IT IS NOT EASY

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Ventilator Associated Lung Injury
 Uneven distribution of Tidal Volumes
 Pro inflammatory mediators

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Mechanisms of VALI in ALI/ARDS
1. Ventilation of lung regions with higher
compliance may be injured by excessive
regional end inspiratory lung volumes
(EILVs).
2. Injury may occur in small bronchioles when
they snap open during inspiration and close
during expiration.
3. Pulmonary parenchyma at the margins
between atelectatic and aerated units may
be injured by excessive stress from the
interdependent connections between
adjacent units.

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 These last two mechanisms are
frequently described with the term
shear forces and may be important
mechanisms of lung injury when
ventilation occurs with relatively low
end expiratory lung volumes (EELVs)
in patients with ALI/ARDS.

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Injury From Excessive EILVs
 The lungs of patients with ALI/ARDS
are susceptible to excessive regional
EILV and over distention injury
 High inspiratory airway pressures
(peak and plateau).

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Volutrauma
 Excessive lung stretch, rather than
pressure, is more likely to be the
injurious force.
 Thus, there is increasing use of the
term volutrauma to refer to the
stretch-induced injury of excessive
inspiratory gas volume.

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Injury From Ventilation at Low
EELVs
 Positive end-expiratory pressure
(PEEP) has lung protective effects
during mechanical ventilation in
isolated lungs, and in intact and
open-chest animals.

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 Effect of PEEP on edema with large
lung volumes
 Injury caused by ventilation with
large Vt and low PEEP.
 Effects of smaller Vts and higher
PEEPs despite similar EILVs.
 The effect of end-expiratory
atelectasis on lung injury.

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PEEP Good Or Bad

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 These and other studies provide
convincing evidence that PEEP has lung
protective effects during mechanical
ventilation.
 However, PEEP also can contribute to
lung injury by raising EILV unless Vt is
simultaneously reduced.
 Moreover, PEEP may cause circulatory
depression from increased pulmonary
vascular resistance and decreased
venous return.

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CV-Based Lung
Protective Strategies
CV strategies designed to protect
the lung from VALI have been
tested in several clinical trials.

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Studies With Reduced EILV
In two case series of patients with
severe ARDS (a total of
approximately 100 patients),
ventilation with small Vts (reduced
EILVs) was associated with mortality
rates that were substantially lower
than rates predicted from the
patients’ acute physiology and
chronic health evaluation (APACHE)
II scores.
Ventilation with lower tidal volumes as compared with
traditional tidal volumes for acute lung injury and the acute
respiratory distress syndrome. N Engl J Med 2000; 342:1301.

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In contrast
 A large multicenter trial with 861
patients with ALI/ARDS found
substantial improvements in clinical
outcomes in the small Vt group.
 The mortality rate prior to discharge
home with unassisted breathing was
significantly reduced (31% vs 40%,
respectively; p , 0.01) among
patients randomized to the small Vt
strategy.

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Studies With Reduced EILV and Increased EELV
A clinical trial in 53 patients with
severe ARDS compared a traditional
CV approach with an approach
designed to protect the lung from
VALI resulting from both excessive
EILV and inadequate EELV.

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In the lung-protection group, pressure
limited modes were used with Vts # 6
mL/kg and peak inspiratory pressures 40
cm H20 to reduce EILV. Increased EELV
was achieved, raising PEEP.
Frequent recruitment maneuvers were
introduced to further increase EELV, and
additional measures were taken to avoid
undesirable collapse or derecruitment of
some lung regions.

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The lung protection approach was
associated with an improved 28-day
survival rate and weaning rate.
In hospital mortality rate was also
reduced
Brower RG, Shanholtz CB, Fessler HE,
et al. Prospective randomized,
controlled clinical trial comparing
traditional vs reduced tidal volume
ventilation in ARDS patients. Crit
CareMed 1999; 27:1492–1498

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Summary
Lung Protective Modes of CV
The body of experimental evidence
strongly suggests that a lung
protective strategy with smaller EILV
and higher EELV will reduce VALI and
improve outcomes in patients with
ALI/ARDS.

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Limitations
Increasing EELV (with higher PEEPs),
especially when it is used in combination
with lower EILVs (smaller Vts) during CV
may cause
 hypoventilation
 respiratory acidosis
 Dyspnea
 circulatory depression
 increased cerebral blood flow
& risk for intracranial hypertension
 increase the requirements for heavy
sedation and neuromuscular blockade.

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Rationale for HFV-Based
Lung Protective
Strategies

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HFV
Advantages over CV
1. HFV uses very small VTs. This allows the use of
higher EELVs to achieve greater levels of lung
recruitment while avoiding injury from excessive
EILV.
2. Respiratory rates with HFV are much higher
than with CV. This allows the maintenance of
normal or near-normal Paco2 levels, even with
very small Vts.
TI - High-frequency percussive ventilation improves
oxygenation in trauma patients with acute respiratory distress
syndrome: a retrospective review.AU - Eastman A; Holland D;
Higgins J; Smith B; Delagarza J; Olson C; Brakenridge S;
Foteh K; Friese RSO - Am J Surg. 2006 Aug;192(2):191-5.

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HFOV Principle
Pressure curves CMV / HFOV

69. 3/18/2022 69
Adults Studies
HFJV was compared to CV in a randomized
trial of 309 oncology patients with body
weight > 20 kg and respiratory failure
requiring mechanical ventilation
In another study, 113 surgical ICU patients
at risk for ARDS were randomized to high-
frequency percussive ventilation (HFPV) or
CV
In a 1997 case series, 17 medical and
surgical patients (age range, 17 to 83
years) with severe ARDS

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Conclusion

71. 3/18/2022 71
Small Vt ventilation to reduce EILV during
CV recently has shown to improve
mortality when compared to a more
traditional Vt approach.
There is also abundant evidence in
experimental animals and, more recently,
in humans to suggest that there are lung
protective effects with higher EELV.
HFV, especially HFO, offers the best
opportunity to achieve greater lung
recruitment without overdistention while
maintaining normal or near-normal acid-
base parameters.

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Starting on HFO
TI - A protocol for high-frequency oscillatory ventilation in adults: results
from a roundtable discussion.
AU - Fessler HE; Derdak S; Ferguson ND; Hager DN; Kacmarek RM;
Thompson BT; Brower RG
SO - Crit Care Med. 2007 Jul;35(7):1649-54.

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Diagrammatic Representation

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SensorMedics
3100B
 Electrically powered,
electronically controlled
piston-diaphragm
oscillator
 Paw of 5 - 55 cmH2O
 Pressure Amplitude
from 8 - 130 cmH2O
 Frequency of 3 - 15 Hz
 % Inspiratory Time
30% - 50%
 Flow rates from 0 - 60
LPM

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Indications
 Diffuse alveolar disease associated
with decreased lung compliance,
hypoxemia & Oxygen index > 30
 Oxygen index=FiO2*Paw/PaO2*100
 Pulmonary barotrauma with air leak
syndrome
 CXR: Pneumothorax
Pneumomediastinum
pneumoperitoneum

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Contraindications
 Heterogenous lung disease
 Increased expiratory resistance

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Initiation
 1. Connect patient to HFO circuit
 2. FiO2 100%
 3. Perform recruitment maneuvers
TI - Tidal volume delivery during high-frequency oscillatory
ventilation in adults with acute respiratory distress syndrome.
AU - Hager DN; Fessler HE; Kaczka DW; Shanholtz CB; Fuld MK;
Simon BA; Brower RG
SO - Crit Care Med. 2007 Jun;35(6):1522-9.

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Initial Settings
 1. FiO2 100%
 2. I:E 1:2 ( Inspiratory Time 33%)
 3. Bias Flow 40 liters/min
 4. Pressure amplitude (∆P)
90cmH2O
 5. mPaw 30 cm of H2O
 6. frequency is determined by
arterial pH immediately prior to HFO

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pH & frequency
 <7.10 3-5Hz
 7.10-7.19 4Hz
 7.20-7.35 5Hz
 >7.35 6Hz

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Oxygenation
 Target SpO2 88-93% & PaO2 55-80mmHg
 After initial RM decrease FiO2 in 0.05-0.1
decrements Q2-5 minutes to target SpO2 88-
93
 If resultant FiO2 is <0.60, adjust mPaw
according to the following chart but if SpO2
falls and you have to increase FiO2 above
0.60:
 Perform a 2nd RM
 Reinitiate HFO with mPaw 34cmH2O
 Follow the chart again

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Algorithm to follow
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Step
1.0
1.0
1.0
0.9
0.8
0.7
0.6
0.6
0.6
0.5
0.4
0.4
0.4
0.4
0.4
0.4
FiO2
38
36
34
34
34
34
34
32
30
30
30
28
26
24
22
20
mPaw
 Fluctuation of 5 cm of H2O around set mPaw
allowable unless oxygenation or ventilation is
compromised; otherwise increase sedation.
 Precede each increase in mPaw by a RM.
Physician may discontinue these routine RMs at
their discretion after 48 hours in study. Do not
decrease mPaw more than 2 cm H2O Q 2Hrs

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If patient develops hypotension during
mPaw titration, stay at lower possible mPaw
1. Reduce mPaw to 30 cm 0f H2O or most
recently tolerated, whichever is lower.
2. Ensure your patient is adequately filled.
3. If patient remains hypotensive despite of
sufficient preload start pressors.
4. If lungs appear over distended on CXR
and/or patient is unresponsive to
increase in mPaw , target a lower mPaw.
5. if FiO2 is > 0.70 for > 2 hrs &
intravascular volume is optimized try a
lower mPaw.

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Recruitment
Maneuvers
TI - Combining high-frequency oscillatory ventilation and recruitment maneuvers in
adults with early acute respiratory distress syndrome: the Treatment with Oscillation and
an Open Lung Strategy (TOOLS) Trial pilot study.AU - Ferguson ND; Chiche JD;
Kacmarek RM; Hallett DC; Mehta S; Findlay GP; Granton JT; Slutsky AS; Stewart TESO
- Crit Care Med. 2005 Mar;33(3):479-86.

85. 3/18/2022 85

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Conventional Ventilation
1. Increase FiO2 to 1.0
2. Set pressure alarm limit to 50 cm H2O.
3. Set apnea alarm to 60 seconds.
4. Change to CPAP/PS mode.
5. Assure pressure support is set at “0” &
tube compensation is “off” ( tube
compensation should always be off for
HFO patients).
6. Increase PEEP to 40 & maintain inflation
for 40 seconds.
7. Lower PEEP to previous set level.
8. Resume previous set mode & reset alarm
limits.
9. Lower FiO2 to previous level.

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When to perform a RM on HFO
 On initiation of HFO
 Immediately preceding any increase in
mPAW dictated by the mPAW/FiO2 chart;
after day 2 this is optional at the
discretion of the attending physician
 If a persistent desaturation (SpO2 <88%
lasting more than 15 minutes) occurs
following an event likely to have caused
derecruitment (e.g. suctioning, accidental
ventilator disconnection, patient
repositioning) ; after day 2 this is optional
at the discretion of the attending physician

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Recruitment Maneuvers for HFO
1. Increase FiO2 to 1.0.
2. Set high pressure alarm to 55 cm H2O.
3. Pause the oscillating membrane (∆ P=0)
4. Eliminate a cuff leak, if present.
5. Slowly raise mPaw to 40 cm H2O over 10 seconds.
6. Maintain mPaw = 40 cm H2O for 40 seconds.
7. Slowly lower mPaw over 10 seconds,to set level prior
to RM if RM was conducted for disconnect or
derecruitment.
8. Adjust level higher to previous if RM performed for
persistent hypoxia.
9. Resume oscillation & reset alarms.
10. Lower the FiO2.

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Ventilation
 Goal pH 7.25-7.35 at highest
possible frequency
 To minimize Vt, maximize frequency
 Adjust frequency rather than ∆ P 90
cm H2O to control pH.

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pH> 7.35
 Increase f by 1 Hz Q 30-60 min to
pH goal or F=10 Hz.
 Decrease delta P from 90 cm only if
f=10 Hz & pH > 7.35 without cuff
leak. If these criteria are met ,
 Decrease delta p by 10 cm H2O Q
30-60 min to reach pH goal.

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pH 7.25 -7.35
 Use highest possible frequency
within this goal range.

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pH 7.15 -7.24
 Decrease f by 1 Hz Q 30-60 to reach
pH goal or f=4

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pH< 7.15
 Decrease f by 1 Hz Q 30-60 min to
pH goal or f=3.
 Consider IV bicarb.

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pH <7.0
 Ensure paralysis.
 If pH remains low for an hour other
rescue measure should be sought.

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Weaning
 Consider Conventional Ventilation
FiO2<0.40
Amplitude<25 cmH2O
Frequency 10-15 Hz
Paw<20 cmH2O
Ti: 33%

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Important Considerations
 CXRs
 Piston centering
 Sedation & paralysis
 Patient & Circuit positioning
 Air way patency
 Recruitment maneuvers after suction

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98. 3/18/2022 98
References

99. 3/18/2022 99
 Standiford, TJ, Morganroth, ML. High-frequency
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