Escolar Documentos
Profissional Documentos
Cultura Documentos
(b)
GUIDELINE
5 5. 1. 4 (b)
DATE DEVELOPED:
July 2006
April 2007
April 2010
DISTRIBUTION:
Neonatal Intensive Care Unit
COMMITTEE RESPONSIBLE FOR RATIFICATION AND REVIEW:
NICU Executive Management Committee
NICU Clinical Practice Committee
DEVELOPED BY:
Paul Craven, Staff Specialist, NICU
Disclaimer
It should be noted that this document reflects what is currently regarded as a safe and appropriate approach
to care. However, as in any clinical situation there may be factors that cannot be covered by a single set of
guidelines, this document should be used as a guide, rather than as a complete authorative statement of
procedures to be followed in respect of each individual presentation. It does not replace the need for the
application of clinical judgment to each individual presentation.
Page 1 of 9
Index
Page
Definition
Incidence of HFOV in Australia and New Zealand
Indications for the use of HFOV
Management Principles of HFOV
Methods to Optimise ventilation
Using HFOV in the clinical set up
Switching from Convention to Oscillation on the Stephanie
Warnings of Using Oscillation with the Stephanie
Adjusting the settings of HFOV in the Clinical setting
Recruitment Manoeuvre for HVOF Stephanie ventilator
Managing Specific Conditions with HFOV
Weaning from HFOV
Trouble shooting with HFOV
2
2
2
3
4
5
6
6
6
6
7
8
8
Definition
High Frequency Oscillatory Ventilation (HFOV), first described in 1977, has been
described as CPAP with wobbles and was thought to reflect a gentler form of ventilation
1
using supra physiological breathing rates.
Incidence of HFOV use in Australia and New Zealand
Data has been collected since 1996 on the use of HFOV in ANZNN. It was defined as
mechanical ventilation presented at high frequencies (small tidal volumes at frequencies
>4hz).
In 1996, 5.9% of all babies recorded in the ANZNN database had HFOV. In 2001 this had
increased to 12.6%, with the majority of infants being of extreme prematurity (30.9% of
those born at 24 weeks vs. 4.0% born at 32 weeks gestation) and the majority suffering
2, 3
from respiratory distress syndrome.
Indications for the use of HFOV
Elective use in preterm infants
Overall there is no effect on mortality at 28 days or term corrected when compared to
those infants conventionally ventilated. In addition there is no overall difference in chronic
lung disease, although there is a trend to a reduction in the HFOV group, especially when
accounting for the significant heterogeneity. There is no difference in short term
neurological outcome, although for those using a low volume recruitment there appeared
in 2 trials to be an increased risk of severe IVH. The outcome long term is inconsistent.
The problem with looking at these trials is the heterogeneity of them. The 2 largest the
HIFI and the UKOS used different volume strategies. In the HIFI, low volume strategies
were used, with no difference in CLD, mortality, but an increase in IVH. In the UKOS,
volume was increased until oxygen requirements were reduced. This difference negated
the increased incidence of IVH.
Of note is the use of differing ventilatory strategies, oscillator types and user experience.
There is a significant reduction in CLD when analysed by type of ventilator but again this
Page 2 of 9
introduced heterogeneity. Thus HFOV should be used at the discretion of the on-call
staff specialist. 4
Rescue ventilation in preterm infants with pulmonary dysfunction
There is no difference in mortality or extended ventilation of rescue HFOV vs. conventional
ventilation. There is a statistical reduction in air leak (NNT=6) of using HFOV but no
difference in gross air leak or pulmonary interstitial emphysema. There is an increased risk
of IVH of any grade (NNT=6) and a trend to an increased incidence of severe IVH in those
using HFOV. Using rescue HFOV should be discussed on a case-by-case basis in
5
consultation with the staff specialist.
Rescue ventilation in term infants with severe pulmonary dysfunction
There is no reduction in mortality or failure of ventilatory method requiring cross over. Of
the one trial meeting entry requirements no difference in length of hospital stay, oxygen
6
therapy or chronic lung disease.
Management Principles of HFOV
Advantages
Lung volume recruitment and CO2 removal, with minimal barotrauma.
It is aimed to support the underlying respiratory disease process and the transition
of fetal to neonatal circulation.
Disadvantages
Ma y limit already poor cardiac reserves in the very sick newborn
The relatively constant pleural pressure and minimal lung volume changes may
impede venous return
HFOV has been described as CPAP with wobbles and the components of the ventilation
include: 8
Mean Airway Pressure (CPAP)- recruitment and sustained inflation of alveoli. (MAP)
Controls O2
Frequency and Amplitude (wobble) of the oscillating waveform imposed onto the CPAP
Controls CO2
Oxygen
Controls O2
To change O2 and CO 2
The oxygenation can b e increased b y:
Increasing the mean airway pressure (MAP) to recruit alveoli- this has the MOST
profound effect on oxygenation.
Optimum MAP corresponds to an AP chest film with 8-9 ribs showing
Increasing the inspired oxygen concentration
Page 3 of 9
.
Methods to optimise ventilation
Bryans Definition
The hallmark of high volume strategy is that the achievement of alveolar expansion
is given higher priority than minimisation of applied pressure, and thus mean airway
pressures early in the treatment of RDS are often higher than in conventional
ventilation. With such a high volume strategy FiO 2 is decreased before pressure and
1
the MAP is only adjusted when FiO 2 requirements do not change.
See diagram over page
Point A - under-inflated with high oxygen requirements
Point B - Well inflated. The lung has opened up. Any further rise in pressure results in
little extra volume recruitment
Point C - over-inflated. CXR determination, 8-10 posterior ribs should be visible
Point D Ventilating on the expiratory limb, achieving maximal inflation with minimal
pressure
Page 4 of 9
Page 5 of 9
Page 6 of 9
Page 7 of 9
Displaced Tube
Obstructed Tube
Pneumothorax
Equipment failure
Increase Amplitude; make sure the chest wall is moving
Reduce oscillator frequency; especially in term infants
Low CO2
Chest wall movement excessive- reduce amplitude
Increase frequency
Change to conventional ventilation
Hypotension/Acidosis
Over distended with venous return obstruction
Reduce MAP
Check for pneumothorax
Consider the need for volume expansion and inotropes
Page 8 of 9
References
1. Bryan AC: The oscillations of high-frequency oscillation. Am J Respir Crit Care Med
2001; 163:816817
2. Donoghue D. The Australian and New Zealand Neonatal Network
3. High Frequency Oscillatory Ventilation workshop- From Art to Science, 2004
4. DJ Henderson-Smart, T Bhuta, F Cools, M Offringa. Elective high frequency oscillatory
ventilation versus conventional ventilation for acute pulmonary dysfunction in preterm
infants. Cochrane Database of Systematic Reviews 2007 Issue 1
5. T Bhuta and DJ Henderson-Smart. Rescue high frequency oscillatory ventilation versus
conventional ventilation for pulmonary dysfunction in preterm infants. Cochrane
Database of Systematic Reviews 2007 Issue 1
6. T Bhuta, RH Clark, DJ Henderson-Smart. Rescue high frequency oscillatory ventilation
vs conventional ventilation for infants with severe pulmonary dysfunction born at or
near term. Cochrane Database of Systematic Reviews 2007 Issue 1
7. Guidelines for the use of High Frequency Oscillatory Ventilation. Princess Margaret
and King Edward Memorial Hospital Neonatal Clinical Care Unit.
8. High frequency Oscillatory Ventilation. Department of Neonatal Medicine Protocol
Book. Royal Prince Alfred Hospital.
Page 9 of 9