1. High frequency ventilation (HFV) uses small tidal volumes and high respiratory rates to ventilate patients with acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). HFV aims to recruit and protect the injured lung better than conventional mechanical ventilation (CMV).
2. Two main types of HFV are high frequency oscillatory ventilation (HFOV) and high frequency jet ventilation (HFJV). HFOV uses a piston to displace gas at 180-900 breaths per minute, while HFJV uses gas jets at 240-480 bpm.
3. Early intervention with HFV may improve outcomes compared to using it as a rescue therapy after prolonged CMV fails. Matching the
High frequency ventilation ppt dr vinit patelVINIT PATEL
HIGH FREQUENCY VENTILATOR FOR NEONATES
NEONATAL VENTILATOR
PPHN,MECHANICAL VENTILATION,ADVANCE VENTILATION,NITRIC OXIDE,SLE 5000,SENSOR MEDICS
DR VINIT PATEL
Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
High frequency ventilation ppt dr vinit patelVINIT PATEL
HIGH FREQUENCY VENTILATOR FOR NEONATES
NEONATAL VENTILATOR
PPHN,MECHANICAL VENTILATION,ADVANCE VENTILATION,NITRIC OXIDE,SLE 5000,SENSOR MEDICS
DR VINIT PATEL
Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
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.
An excellent tool to treat refractory hypoxia. Target audience are ICU junior physicians and Respiratory Therapists. It will take away the fear of "What is APRV?" from your hearts and you will feel ready to give it a try.
Basic information on the Graphics displayed on the Ventilators. Prepared to educate about the graphics to train the professionals who work with Ventilators.
High frequency oscillatory ventilation (HFOV) is a type of mechanical ventilation that uses a constant distending pressure (mean airway pressure [MAP]) with pressure variations oscillating around the MAP at very high rates (up to 900 cycles per minute). This creates small tidal volumes, often less than the dead space.
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.
An excellent tool to treat refractory hypoxia. Target audience are ICU junior physicians and Respiratory Therapists. It will take away the fear of "What is APRV?" from your hearts and you will feel ready to give it a try.
Basic information on the Graphics displayed on the Ventilators. Prepared to educate about the graphics to train the professionals who work with Ventilators.
High frequency oscillatory ventilation (HFOV) is a type of mechanical ventilation that uses a constant distending pressure (mean airway pressure [MAP]) with pressure variations oscillating around the MAP at very high rates (up to 900 cycles per minute). This creates small tidal volumes, often less than the dead space.
Presented by Dr.Nial Ferguson at Pulmonary Medicine Update Course held at Cairo, Egypt. Pulmonary Medicine Update Course is the leading Pulmonary Critical Care event in Egypt. Organized by Scribe www.scribeofegypt.com
Presentation of Dr. Dean Hess at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
The “How To” of BiVent
Created by: David Pitts II, RRT
Clinical Applications Specialist, Maquet
Birmingham, Alabama
Sponsored by Maquet, Inc – Servo Ventilators
Postoperative Ventilation in Paediatric Cardiac Surgical Patientsdr amarja nagre
In paediatric patients with congenital heart diseases,postoperative management is as important as surgical procedure.Here is discussion regarding the same.
Postoperative Ventilation in Paediatric Cardiac Surgical Patientsdr amarja nagre
In paediatric patients with congenital heart diseases,postoperative care is as important as surgical procedure.Here is discussion regarding various strategies for their ventilation.
The Changing Role of the Coronary Care Cardiologist & The Emerging Role of Ca...Dr.Mahmoud Abbas
The Changing Role of the Coronary Care Cardiologist
&
The Emerging Role of Cardiac Intensive Care Specialists lecture presented by Dr Sherif Mokhtar, President ECCCP at the Egyptian Spanish Critical care Symposium held at Cairo, Egypt on 11 May 2023
Drug induced Kidney Injury in the ICU. Presentation by Dr Sandra Kane Gill , President Society of Critical Care Medicine (SCCM) , USA at the Egyptian Critical care Summit 2022 conference , organized by the Egyptian College of Critical care Physicians (ECCCP) , Egypt
Using Novel Kidney Biomarkers to Guide Drug Therapy.pdfDr.Mahmoud Abbas
Using Novel Kidney Biomarkers to Guide Drug Therapy: Presentation by Dr Sandra Gill , President SCCM at the Egyptian Critical Care Summit 2022 held at Cairo, Egypt and organized by the Egyptian College of Critical care Physicians (ECCCP)
Presentation by Dr Marwa Atef , National Research Center, Cairo, Egypt . Presented at Cairo Textile Week 2021 , the leading textiles conference in Egypt
Cairo Textile Week 2021 Conference -Egypt Textiles & Home Textiles Export Cou...Dr.Mahmoud Abbas
Egyptian Textiles Export
Opportunities & Requirements
Presentation by Engineer Hany Salam, CEO Salam Textiles, Board member Egypt Textiles & Home Textiles
Export Council (THTEC)
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
1. Pediatric High Frequency
Ventilation:
A Clinical Approach
Ira M. Cheifetz, MD, FCCM, FAARC
Professor of Pediatrics
Chief, Pediatric Critical Care Medicine
Medical Director, PICU
Duke Children’s Hospital
2. Pediatric ALI and ARDS
♦ HFOV: Arnold study (Crit Care Med, 1994)
but control group was pre-ARDS
pre-ARDS
Network study (i.e., large tidal volume)
♦ HFJV: No data
♦ So, why use HFV in pediatrics?
physiology
–
– pathophysiology
– clinical experience
3. High Frequency Ventilation:
A Clinical Approach
♦ Pediatric ALI / ARDS
♦ HFV: Physics and Physiology
– HFOV
– HFJV
♦ Why? When?
13. ARDS
‘Infant’ lung sitting on
consolidated lung:
♦ VT of 6 - 10 ml/kg based
T
on weight
♦ VT may be > 20 ml/kg
T
based on open lung units
14. Pulmonary Injury Sequence
Froese A, Crit Care Med, 1997
Two injury zones during mechanical ventilation:
low lung volume
♦
ventilation tears
adhesive surfaces
♦ high lung volume
ventilation over-
distends resulting
in volutrauma
15.
16. HFV Goals
♦ Establish & maintain adequate FRC
normalize lung architecture
–
improve compliance
–
– reduced PVR
– improve gas exchange
♦ Provide an adequate minute volume
while minimizing regional lung over-
distension.
17. Optimizing HFV
General Guidelines:
♦ Have a clear concept of how HFV works.
♦ Know determinants of ventilation and
oxygenation with your HFV device(s).
♦ Recognize ‘benefits’ of certain strategies
vs. ‘risks’ of complications.
♦ Match ventilator strategy to patient’s
predominant pathophysiology.
♦ Be prepared to adjust strategy as patient's
condition changes.
18. Reducing the Volume-Cost of Ventilation
Each point represents the VT that yielded PCO2 = 40 torr.
2
12
10
Tidal Volume (ml/kg)
CMV
8
6
4
HFV anatomic deadspace
2
0
30 60 90 120 180 240 300 360 420 480 540 600
Freq (bpm)
Bunnell et al. Am Rev Resp Dis. 1978;117(Part 2):289.
19. ∆P is key to controlling PaCO2
∆P = PIP – PEEP
∆P VT
X
VCO2 ≈ f x VT
For HFV, X = 1.5-2.5
20. High Frequency Ventilation:
A Clinical Approach
♦ Pediatric ALI / ARDS
♦ HFV: Physics and Physiology
– HFOV
– HFJV
♦ Why? When?
21. HFOV
♦ Tidal volume < dead space volume
♦ Frequency = 180 - 900 bpm (3 - 15 Hz)
♦ Piston displacement of gas
♦ Active, intermittent exhalation
22.
23. HFOV
Approved in 1991 for neonatal resp failure
♦
– approved for ‘early intervention’
– not classified as a ‘rescue device’
♦ Approved in 1995 for peds resp failure
– no ‘weight limit’
– for selected patients failing CMV
(OI > 13 on 2 consecutive ABGs in 6 hrs)
♦ Approved in 2001 for adult ARDS pts
– 3100B approved for pts > 35 kg
27. HFOV: Neonatal Clinical Data
RCTs of the 3100A have demonstrated:
– ↓ severity of CLD in RDS infants
– ↓ cost of hospitalization for RDS
– ↓ need for ECMO in eligible candidates
– ↓ air leak in severe RDS
30. Adult ARDS and HFOV
30 Day Mortality
p
HFOV CMV % Difference
37% 52% 29% 0.098
MOAT Trial, Am J Respir Crit Care Med, 2002.
31. Predictors of Outcome: MOAT2
OI = (Paw x FiO2 x 100) / PaO2
2 2
♦ OI at 16 hrs was the only significant
predictor of mortality in a stepwise
logistic regression analysis.
♦ OI 15 at 16 hrs → 35% mortality
♦ OI 25 at 16 hrs → 55% mortality
MOAT Trial, Am J Respir Crit Care Med, 2002.
32. Conclusions: MOAT2
♦ HFOV for treatment of severe ARDS has a
90% predictive value for reducing mortality
by 29%.
♦ Trend in ↓ mortality (20%) is recognizable
at 6 mos.
♦ Benefits related to chronic lung changes
may exist as reflected by the small but
extended use of respiratory support in the
CMV group.
MOAT Trial, Am J Respir Crit Care Med, 2002.
33. Experience & Data Suggest
♦ Inverse relationship between prior days
of CMV & ability to ventilate
♦ > 72 hrs of CMV raised odds of CLD by
25 fold
♦ > 10 days of CMV ↑ risk for mortality
♦ OI > 42 at 48 hours ↑ risk for mortality
Arnold, Crit Care Med, 1994.
MOAT Trial, Am J Respir Crit Care Med, 2002.
34. HFOV: Clinical Indications
♦ ALI / ARDS – all ages / weights
– OI > 13 on two consecutive ABGs
within 6 hours
– ‘excessive’ PIP
♦ Air leak syndrome
35. HFOV: Gas Exchange
♦ Oxygenation and ventilation are
decoupled.
♦ PaO2 → Paw and FiO2
PaO2 FiO2
♦ PaCO2 → amplitude and frequency
PaCO2
♦ Minor exception – % inspiratory time
36. General Approach to Peds ALI
♦ Rate: based on pt weight and
anticipated resonant frequency of the
lung.
38. General Approach to Peds ALI
♦ Rate: based on pt weight and
anticipated resonant frequency of the
lung.
♦ Paw: titrate to ideal lung volume and,
thus, optimal oxygenation.
♦ Amplitude: titrate for desired
ventilation; permissive hypercapnia.
♦ % inspiratory time: generally 33%
39. A Clinical Caution….
If amplitude is ≥ 3 times Paw,
PEEP generated by HFOV is ≤ 0.
Paw Amp Hz PEEP
15 50 5 0
15 50 6 0
15 50 7 0
Bass et al; in progress.
40. High Frequency Ventilation:
A Clinical Approach
♦ Pediatric ALI / ARDS
♦ HFV: Physics and Physiology
– HFOV
– HFJV
♦ Why? When?
41. HFJV
♦ Tidal volume < dead space volume
♦ Frequency = 240 - 480 bpm
♦ ‘Jet’ pulse of gas
♦ Passive, continuous exhalation
♦ FDA approved in 1988
42. Flow Streaming Reduces Effective
Dead Space
Inspired gas jets into the airways at
high velocity but low pressure.
CO 2
CO2
Gas swirls down the airways,
splitting at bifurcations, seeking
path of least resistance in the
center of the airways.
The train of tiny tidal volume
pockets moves high pO2 gas
close to alveoli, while CO2 is
compressed against airway walls.
43. Exhalation During HFJV
CO 2
Exhaled gas swirls out CO
2
CO
2
around the incoming gas,
CO
2
sweeping the CO2-rich
CO2
deadspace gas out along
the airway walls. CO
2
This action may help
remove excess
secretions and debris.
44. HFJV: Clinical Indications
♦ Neonatal lung injury and air leak
syndrome – FDA approved
♦ Peds ALI / ARDS – not FDA approved
♦ Need for improved CO2 elimination
CO2
– ALI + bronchospasm (i.e. bronchiolitis +
pneumonitis)
– ALI with significant pulm hypertension
– RV dysfunction / passive pulm blood flow
♦ Note: weight limitation – based on pathophys
46. High Frequency Ventilation:
A Clinical Approach
♦ Pediatric ALI / ARDS
♦ HFV: Physics and Physiology
– HFOV
– HFJV
♦ Why? When?
47. HFOV
♦ Advantages
ability to generate high mean pressures while
–
limiting peak pressures
works for all size and age pts (3100 A / B)
–
FDA approved for peds ALI / ARDS
–
air leak syndrome
–
♦ Disadvantages
less efficient exhalation: intermittent, active
–
increased need for sedation and NMB
–
no indication of VT delivery or lung volume
– T
48. Pediatric Options for HFV
Early intervention
vs.
Rescue therapy
Why wait to start HFV??
49. Pediatric HFV
♦ HFV is capable of recruiting & protecting
♦
the acutely injured lung presumably
better than CMV.
♦ Time to intervention is a critical factor in
♦
determining the outcome of patients
managed with HFV.
50. Optimizing HFV
General Guidelines:
♦ Have a clear concept of how HFV works.
♦ Know determinants of ‘ventilation’ and
oxygenation with your HFV device(s).
♦ Recognize ‘benefits’ of certain settings vs.
‘risks’ of complications.
♦ Match ventilator strategy to patient’s
predominant pathophysiology.
♦ Be prepared to adjust strategy as patient
condition changes.
51. Pediatric ALI and ARDS
♦ HFV: Why use it?
– Physiology, pathophysiology, clinical
experience, and some data.
♦ CMV Modes:
– No data support any mode over another.
– Literature does support low tidal volume
ventilation. (ARDS Network, NEJM, 2000)
– HFV is the ultimate in low tidal volume
ventilation.