fabian HFO Quick Guide Feb 2013

Turn ventilator on: • Once patient circuit is set up, turn ventilator on by pushing the green ON/OFF button

• After a 20s startup and selftest routine, the calibration screen comes up Calibrate flow sensor now: • Occlude one or both end(s) of flow sensor by hand using a sterile glove • Touch Flow Cal button > sensor is tested and calibration starts • After 5s, the green tick indicates end of calibration procedure • If NCPAP or DUOPAP mode are in use, the flow sensor is automatically deactivated Oxygen sensor calibration: There is no need for a manual oxygen sensor calibration (done automatically in 24 hours intervalls) There is no alteration of the gas going to patient during this procedure

Flowsensor calibration:

Ventilation Parameter setting: • Select desired ventilation mode first Important: By pushing the button, the parameters of the ventilation mode can be preset. (button turns yellow), the new ventilation mode is only activated by re-tapping! As long as mode is not confirmed, ventilator will continue ventilation in previous mode

• Select parameter you wish to change > button turns green > Adjust parameter by rotating the rotary knob and confirm setting either by tapping respective button or rotary knob > parameter button turns blue again • Only parameters necessary for selected mode, will appear on the screen Trigger button for instance is only visible in modes were trigger is used

Use of InfantFlow mode: (Variable Flow Generators) If single limb systems like the InfantFlow or mediJet are used, the connection between ventilator outlet and humidifier inlet is a special one. If standard tubing is used, there is no pressure build up!

Use InfantFlow connecting tube partnumber 7067!

Turn off of the ventilator: • fabianHFO has an integrated safety system in case of accidentally turning off the ventilator

• To turn off the device, push the green button in the status line are gone

for at least 5s until all the blue points

• Press alarm mute button to confirm action

Fix keys: Manual breath

Alarm mute for 120s and reset of visual alarm

Preoxygenation, flush

ON / OFF

Nebulizer Aeroneb® (optional)

START / STOP ventilation, stand-by

Home screen (parameter setting)

Grafics, waves, loops, trends

Calibration menu (flow sensor)

Alarm limits, alarm history, loudness

Ventilation modes Description of the ventilation modes on fabian HFO ventilator: Available modes are: IPPV (CMV) SIPPV (ASSIST) SIMV SIMV+PSV PSV CPAP nCPAP duoPAP HFO O2 Therapy VG VL

Intermittent Positive Pressure Ventilation Synchronised Intermittent Positive Pressure Ventilation (Assist Controlled Ventilation) Synchronised Intermittent Mandatory Ventilation Synchronised Intermittent Mandatory Ventilation with Pressure Support Pressure Support Ventilation Continuous Positive Airway Pressure Ventilation Nasal CPAP with Flow Generators Two Level Nasal CPAP with Flow Generators High Frequency Oscillatory Ventilation High or Low Flow Oxygen Therapy (with nasal cannulas) Volume Guaranteed Ventilation Volume Limited Ventilation

IMPORTANT: Volume Guarantee function is available in the following modes: IPPV, SIPPV (ASSIST), SIMV, SIMV+PSV, PSV and HFO In the SIMV modes, the Volume Guarantee function is only valid for the SIMV breath and not for the PSV breath. In PSV mode, the VG function is active for the PSV breath as well as for the back up breath in case of APNEA. The backup ventilation „kicks in“ after the set Apnea time. If Apnea alarm is set to OFF, the backup ventilation starts right after one period of expiratory time (Te).

Alarm screen, alarm limit setting To access the alarm limits screen, push the alarm limits button To adjust alarm limits, move cursor to the parameter, push rotary knob and adjust value according your clinical guidelines Note ! In PSV mode, the Apnea delay time determines after which delay the backup ventilation will start. To allow the baby breathing with short periods of apnea, the Apnea time should be set somewhere in between 3s and 6s

Autoset MV Frequency, Apnea, Ppeak PEEP

Sets the alarm limit automatically based on measured value upper limit 80% above measured value, lower limit 50% below measured value 50% above measured value 10 seconds 3cmH2O above measured value 3 cmH2O below measured value

Alarm loudness can be set in 3 different levels Show Log opens the alarm history logfile

IPPV (CMV) In IPPV, there is no synchronisation with patients breathing pattern. This mode should only be used for patients without spontaneous breathing efforts. Sedated patients for instance Settings to start with: I-Flow between 8 LPM E-Flow 6 LPM Rate between 55 and 60 BPM Inspiratory time Ti between 0.3s and 0.4s Pinsp between 15 – 18cmH2O PEEP 4 - 6 cmH2O To adjust wave form, use I-Flow. For square waveform increase, for accelerating or sine wave, decrease I-Flow. Recommended alarm settings: • Low minute volume • Low PEEP • Ppeak

SIPPV (ASSIST) Every inspiratory effort triggers a breath with a fixed inspiratory time and inspiratory pressure. The minimum rate per minute is the preset one. A patient triggered breath is colored green, a none triggered is grey. Note: It is important that the Ti is watched carefully in this mode – too long a set Ti in an infant with tachypnoea will result in a short expiratory time (Te) and leads to air trapping, with the risk of air leak. Settings to start with: I-Flow 8 LPM E-Flow 6 LPM Rate 40 BPM Inspiratory time between 0.3s and 0.4s Pinsp between 16 – 18cmH2O PEEP 4 - 6 cmH2O Recommended alarms: Same as IPPV but in addition Respiratory Rate to alert in case of Hyperventilation Try to achieve an exhaled tidal volume of about 5 – 6 ml/kg bodyweight. To increase Tidal Volume, increase Pinsp and eventually rise PEEP

SIPPV (ASSIST) with VG (Volume Guarantee) If VG is added to the SIPPV (ASSIST) ventilation, each breath is maintained at same exhaled tidal volume. In case of an improvement of lung compliance, the Pinsp is automatically reduced Every single inspiratory effort of the patient is supported with a mechanical breath with fixed inspiratory time and fixed Inspiratory Pressure. If the breath was triggered by patient, it is colored green, if none triggered, grey. The baby controls the rate of ventilation. Settings to start with: I-Flow 8 LPM E-Flow 6 LPM Rate between 35 and 40 BPM Inspiratory time between 0.3s and 0.4s Pinsp between 16 – 18cmH2O PEEP 4 - 6 cmH2O How to start VG function: Step 1 Setup ventilator in SIPPV (ASSIST) and start ventilation Step 2 Once the Exhaled Tidal Volume VTe reading is constant, press Vguarant button > turns green

Step 3 Turn rotary knob clockwise > current Tidal Volume VTe is taken from readings. Pinsp button changes to orange colour and P insp is automatically increased by 5 cmH2O to allow ventilator to compensate for a changing lung compliance. Confirm setting by pushing rotary knob. Setting is accepted if button turns to blue colour again. Triggered and none triggered breath are independently supported based on lung compliance.

Step 4 If Volume guarantee function is deactivated, the Pinsp pressure which was necessary to deliver preset target volume, will be used. In case of a flow sensor failure, the ventilator automatically memorizes the last correct Ppeak value and continues ventilation at this level, until flow sensor problem is solved Meaning of the orange Pinsp button: Maximum pressure to achive target volume, allowed by the user, but ventilator will always use lowest possible Ppeak to deliver the target volume

The following graphic shows different support of triggered and none triggered breath. To maintain the preset exhaled tidal volume, the ventilator changes the Ppeak breath to breath by maximum change of 3 cmH2O.

Note: If the preset target volume is not achievable within the set Pinsp, a warning message „Tidal Volume not reached“ is displayed in the status line underlined by an acoustic beep every 10s. An arrow in the Pinsp button pointing upward indicating use of a higher Pinsp is necessary to achieve target volume

SIMV+PSV The ventilator synchronizes patients inspiratory efforts and delivers a fixed amount of synchronised mechanical breath with preset inspiratory time. Spontaneous inspiratory efforts in between mechanical breath are supported with pressure support level PPSV . Patient determines begin and end of PSV breath depending on the preset flow termination criteria. The I-Time button coloured orange, indicating set I-Time is only valid for SIMV breath and represents max. I-Time in case flow termination criteria isn‘t met. (in case of high ET tube leakage) Settings to start with: I-Flow 8 LPM E-Flow 8 LPM Rate between 20 to 30 BPM Inspiratory time between 0.3s and 0.4s Pinsp between 16 – 18cmH2O P psv 16 – 18 cmH2O PEEP 4 - 6 cmH2O The minimum pressure difference between PEEP and PPSV is always 2 cmH2O and PPSV is max same level as Pinsp. If Volume Guarantee is added, the VG criteria is only valid for the SIMV breath. Not for the PSV breath.

PSV The ventilator synchronizes the patients inspiratory effort and delivers a breath at fixed pressure levels but variable I-Time is controlled by patient based on preset flow termination criteria. The rate is controlled by the patient. Settings to start with: I-Flow 8 LPM E-Flow 8 LPM Rate between 30 to 40 BPM Inspiratory time between 0.3s and 0.4s Pinsp between 16 – 18cmH2O P psv 16 – 18 cmH2O PEEP 4 - 6 cmH2O Important: In PSV mode, the apnea backup ventilation will start after the preset apnea delay set in the alarm menu. Make sure to set this apnea delay to about 4 – 6s, because babies tend to have short periodes of apnea and you don‘t want the ventilator to kick in to early. If apnea is set to OFF, the ventilator starts backup after E-Time. The minimum pressure difference between PEEP and PPSV is always 2 cmH2O and PPSV is max same level as Pinsp.

PSV+VG If Volume Guarantee is added to PSV, the ventilator automatically is adjusting the PPSV level necessary to maintain preset target volume. In case of an apnea, the ventilator will start cycling at preset rate and PBackup. As soon as spontaneous activity restarts, the backup stopps. Settings to start with: I-Flow E-Flow Rate Inspiratory time Pbackup = Pinsp

8 LPM 8 LPM between 30 to 40 BPM between 0.3s and 0.4s between 16 – 18cmH2O

Safety backup rate in case of apnea Used for backup and as max I-Time PBackup is the Pinsp used during apnea backup ventilation

PPSV 16 – 18 cmH2O PEEP 4 - 6 cmH2O The minimum pressure difference between PEEP and PPSV is always 2 cmH2O and PPSV is max same level as Pinsp. Note: PSV breath as well as apnea backup breath are volume targeted breath in this mode. The delay to start backup ventilation is set with the Apnea time in alarm limt screen. If Apnea is set to OFF > backup starts after E-Time

HFO Ventilation High Frequency Oscillatory ventilation uses the following settings: Settings to start with: Flow MAP Amplitude Frequency 1kg I:E Ratio Pmanual Vguarant

8 LPM about 2 cmH2O above MAP used for conventional ventilation start at about 22 cmH2O 12 to 15Hz for babies below 1kg and 8 – 12Hz for babies above 1:2 If used in your clinical guidelines for lung recruitment, otherwise deactivate in ventilation menu Set at 2ml per kg bodyweight depending your clinical guidelines

CPAP The CPAP mode can be used for intubated patient as well as for nasal CPAP. If used with nasal CPAP systems like F&P bubble CPAP, Hudson or similar, the flow sensor must be deactivated manually in the calibration screen. The ventilator automatically compensates leaks by increasing flow to max Flowmin plus100% to avoid CPAP pressure drop. Settings to start with: FLOW min CPAP Pmanual Backup

8 LPM 5 cmH2O 12 cmH2O OFF

Important: Make sure the flow sensor is deactivated, otherwise the apnea alarm is triggered all times. Use alternative system for apnea detection. For Variable Flow systems like Infantflow®, Inspire™ or Medijet®, please use the option NCPAP and DUOPAP if available in your unit.

O2 Therapy O2 Therapy is an option which allows use of a continous flow of blended gas, from 1 – 15 LPM. Nasal cannulas of various makes like F&P, Atom or similar can be used. There are no alarm functions active in this mode, except for the set FiO2 For weaning purposes, this mode can also be used in conjunction with variable flow systems like Infantflow®, Inspire™ or Medijet®, however, there won‘t be any alarm settings on pressure monitoring. Note: This mode can also be used to put the ventilator in standby mode. By setting a flow of 4 LPM, the humidifier dual servo temperature controls remain active, so no need to switch it off in case of short term standby mode.

Features Grafics: Waves:

Displays 3 waveforms, Pressure, Flow and Volume simultaneously

Freeze:

Freezes the waves or Loops

Loops:

Pressure-Volume and Flow-Volume Loops

Trends:

up to 5 days trending of measured values

Safe Loop:

The safe Loop function stores one Loop and keep it as reference until a new Loop is safed

Waves:

Manual scaling mode. Use up and down keys for scaling grafics

Loops:

Trends:

Sub Menu: The submenu allows access to finetune some of the ventilation modes • Manual breath • Flow termination criteria for PSV ventilation • Flush time • ………….

NO application Important: If Nitric Oxyde Systems like the InoMax or InoVent are used to deliver NO, make sure the setup of the circuit is done as per below graphic. It is important to place the flow sensor of the NO delivery system directly at the freshgas outlet of the fabian HFO. The measuring line shall be placed close to patient in inspiratory limb.