CareFusion 3100B Pocket Guide Rev C Aug 2011

Pocket guide 3100B high frequency oscillatory ventilator

This clinician’s guide describes equipment set-up and patient management procedures for the 3100B High Frequency Oscillatory Ventilator (HFOV).

Warning Do not use this pocket guide as a substitute for (1) reading and understanding the operator’s manual, (2) as a substitute for being properly trained or (3) as a substitute for competency using the 3100B High Frequency Oscillatory Ventilator. Use this document as a guideline for initiating and managing the patient on HFOV. Management of a patient on the 3100B HFOV must be altered based on the patient’s individual clinical needs. This document is not intended to be used as a substitute for clinical experience or medical guidance.

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Contents Indications and contraindications...1 Things to consider before placing the patient on HFOV...4 Pre-use checklist...6 Patient circuit calibration...8 Ventilator performance check...10 Initial settings and management...12 Managing oxygenation and ventilation...16 Assessment of the patient on HFOV...18 Documentation of oscillator settings...21 Weaning HFOV and transitioning to conventional ventilation...22 Transitioning to conventional ventilation...23 Troubleshooting...24 Recruitment maneuvers for adult patients on HFOV...34 Cuff leak procedure...36 Outcome assessment form...41 Useful information...42

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Indications and contraindications Indications The 3100B High Frequency Oscillatory Ventilator is indicated for use in the ventilatory support and treatment of selected patients weighing 35 kilograms and greater with acute respiratory failure. Contraindications The 3100B High Frequency Oscillatory Ventilator has no specific contraindications.

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Identifying patients for high-frequency oscillatory ventilation Patients with ALI or ARDS, weighing 35 kilograms or greater, who are currently failing on conventional ventilation with a protective lung strategy, will benefit from HFOV. The following criteria are generally used for determining the feasibility of using HFOV. •

FiO2 ≥ 60, PEEP ≥ 10 with a P/F ratio < 200

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Plateau pressure > 30 cmH2O

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Presence of bilateral infiltrates on the chest x-ray consistent with ARDS

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Oxygenation index > 24 Note: Several clinical papers and randomized control trials have demonstrated that the earlier application of HFOV on patients with severe ARDS may be important for successful outcomes.

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The Multicenter Oscillatory Ventilation for Acute Respiratory Distress Syndrome Trial1 (MOAT2) excluded severe COPD and asthma patients from the RCT trial of the 3100B HFOV. High frequency oscillatory ventilation is recognized as less effective in diseases with increased airway resistance and using it in such cases may potentially result in air trapping and hyperinflation.

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Things to consider before placing the patient on HFOV •

Hemodynamic status: – The patient should be hemodynamically stable with a mean arterial pressure of at least 75 mmHg – If mean arterial pressure is less than 75 mmHg, consider fluids and/or vasopressors to optimize the hemodynamic status before starting the oscillator

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Obtain ABG – Ideally, pH should be greater than 7.2 – If pH is less than 7.2, consider correcting with a buffer for the transition

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Patient’s sedation status: – You may need to consider sedation and neuromuscular blockades for transition-due to the fixed Bias Flow of the device, patients are unable to actively breathe and maintain a stable airway pressure and lung volume – Once transitioned, patients may be able to be maintained on sedation only 4

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Ensure the patient has had a recent chest x-ray

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Consider the type of mattress the patient is on-you should have the ability to firm up the mattress if needed

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Verify whether the patient requires an off-unit procedure such as a CT scan or MRI; if this is the case, consider doing the off-unit procedure before placing the patient on HFOV

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If using an in-line suction catheter, ensure the fit to the circuit and suction patient before placing on HFOV

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Give a brief explanation of HFOV to the family and patient to prepare them for noise, chest wiggle, etc.

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If lung recruitment maneuvers are not part of your ventilation protocol, speak with the physician to consider Treatment with Oscillation and Open Lung Strategy (TOOLS)2

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Pre-use checklist 1. Connect the source gases to system. 2. Connect the power to system. 3. Check that the patient circuit support is installed on the system. 4. Connect the patient circuit and the humidifier to the system. 5. Connect the patient circuit control and pressure sense lines to the system. 6. Turn on the power. 7. Check that the source gas lights are off. 8. Check that the start/stop light is off. 9. Check that the alarm silence light is on. 10. Perform the patient-circuit calibration described in the following section. 11. Perform verification performance. 12. Perform the alarm-check procedure as described in the Operators Manual.

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13. Preset the flow, frequency, % inspiratory time, power and running mean airway pressure. 14. Set the Max Paw and Min Paw switches. 15. Set the blender and humidifier controls for the desired operation. 16. Remove the stopper from the patient circuit and connect it to the patient’s ET tube.

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Patient circuit calibration Perform the patient circuit calibration procedure before ventilating a patient. Each circuit that is used on the oscillator must be calibrated. The circuit calibration procedure verifies the circuit is leak-free and will hold pressure. Perform this procedure before placing a patient on the 3100B HFOV and anytime a circuit component is changed. 1. Insert the stopper in the patient circuit wye and turn on the bias flow gas. 2. Rotate the ADJUST control to Max. 3. Set the Max Paw Alarm to 59 cmH2O. 4. Set the bias flow to exactly 20 LPM (the middle of the ball is at the line-you may need to bend down to see this accurately.). 5. Depress and hold RESET (Oscillator OFF).

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6. Observe the mean pressure display and adjust the patient circuit calibration screw for a reading of 39 to 43 cmH2O. a. Before adjusting the calibration screw, confirm there are no leaks, the bias flow is at 20 LPM and the circuit is set up correctly. See the troubleshooting guide for more information. b. Use caution when adjusting the calibration screw. Do not over tighten or apply excessive force because equipment damage may occur.

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Ventilator performance check The ventilator performance check ensures the 3100B HFOV is functioning properly. Perform this procedure before placing a patient on the 3100B HFOV. Insert the stopper in the patient circuit wye and turn on both gas sources. 1. Turn the Adjust control to the 12 o’clock position. 2. Set the bias flow at 30 LPM. 3. Pressurize the system by pressing and holding Reset and Adjust for a mean pressure of 29 to 31 cmH2O. 4. Set the frequency to 6.0 Hz, % I–time to 33 and press START/STOP to start the oscillator. 5. Set the power to 6.0. 6. Observe the following parameters using the appropriate altitude range and verify they fall within the ranges specified.

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Verify the following parameters according to the altitude of your hospital.

Altitude (feet)

mPAW (cmH2O)

P (cmH2O)

0 to 2,000

26 to 34

113 to 135

2,000 to 4,000

26 to 34

104 to 125

4,000 to 6,000

26 to 34

99 to 115

6,000 to 8,000

26 to 34

86 to 105

Note: See troubleshooting on pg. 22 for additional information.

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Initial settings and management 1. Set bias flow between 25 to 40 LPM. Patients with severe air-leak syndrome or cuff leak may require higher set Bias Flow to achieve the desired mPaw. 2. Set the initial mean airway pressure (mPaw) at 5 cmH2O pressure above the conventional ventilator mPaw. a. You may consider a recruitment maneuver first if the patient is extremely hypoxic by applying 40 cmH2O for 40 to 60 seconds. b. If oxygenation worsens, increase mPaw in 3 to 5 cmH2O increments every 30 minutes until the maximum setting is reached. Note: Oxygenation typically may worsen in the first 30 minutes of recruitment in severe ARDS.

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c. Check a chest-x-ray within one to four hours of initiating HFOV to assess lung volume. 3. Set the power at 4.0 and rapidly increase it to achieve chest wiggle (a visual vibration from shoulders to mid-thigh area). a. Transcutaneous monitoring for CO2 (TcCO2) should be considered. b. If PaCO2 worsens (but pH > 7.2), increase the power setting to achieve a change of amplitude in 10 cmH2O pressure increments every 30 minutes up to the maximum setting. c.

If pH is < than 7.2, consider buffering pH.

d. An abrupt rise in PaCO2 in an otherwise stable patient should be considered an obstruction of the endotracheal tube until proven otherwise. Note: Some studies suggest a higher frequency setting (and corresponding higher amplitude) may be more lung-protective.

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4. Set Hz at a range of 5 to 6 initially. a. You may decrease the Hz if you cannot control the PaCO2 with amplitude of approximately 90 cmH2O. b. Decrease the Hz by 1 Hz at a time every 30 minutes until you reach a level of 3 Hz. 5. Set IT % at 33%. You may increase this value up to 50% if you are unable to ventilate by increasing the amplitude or by first decreasing the frequency. Caution! Using flows higher than 40 LPM may increase the risk of increasing PaCO2 due to decreasing the effectiveness of the active exhalation. 6. For severe hypercapnea with pH > 7.2, consider decreasing the endotracheal tube cuff inflation to produce a leak. a. Reduce the inflation of the cuff until you see a drop in the mPaw by 5 cmH2O. Readjust the bias flow to correct the mPaw level. b. Rule out obstruction in endotracheal tube with bronchoscopy. 14

7. Initial FiO2 at transition to HFOV should be set to 1.0. Alternatively, increase current FiO2 by 10%. 8. As oxygenation improves, gradually wean FiO2 to 0.40, and then slowly reduce mPaw 2 to 3 cmH2O every four to six hours until mPaw is in a 22 to 24 cmH2O range. 9. When the above goal is met (but no sooner than 24 hours), switch to PCV or APRV. Initial settings: • PIP titrated to achieve delivered Vt of 6 to 8 mL/kg • •

Plateau Pressure (Pplat): < 35 cmH2O I:E of 1:1

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PEEP: 12 cmH2O Rate: 20 to 25 / min

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Mean airway pressure should be about 20 cmH2O (± 2 cmH2O).

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Managing oxygenation and ventilation If h PaO2 1. Wean FiO2 slowly (5%) to < 0.60. Re-check the x-ray for lung volume assessment. If lung volume is adequate, continue to wean FiO2 to 0.40. If lung volume is approaching a hyperinflation state, consider weaning mPaw by 1 to 2 cmH2O and continue to wean FiO2 to 0.40. 2. Once FiO2 is < 0.40, attempt to wean mPaw by 1 to 2 every four to six hours, ensuring maintenance of adequate lung inflation and oxygenation. If i PaO2 1.

h FiO2 as needed to 1.0.

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h mPaw by 3 to 5 every 20 to 30 minutes to obtain adequate lung inflation and oxygenation.

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Check the x-ray to ensure appropriate lung volume.

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Check for hemodynamic status for adequate perfusion.

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