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					Neonatal Respiratory Care                                                                                            Page 1 of 4
Procedure                                         HFJV Policy and Procedure

                         Approved by                         Date Approved                Document Details

       Daniel S. Baird,_RRT, MBA___________                  June 2, 2008__               Origin Date: May 2008
       Neonatal Service RT Program Manager

       Leif Nelin, MD_______________________                 June 2, 2008__               Updated: May 5, 2008
       Neonatal Service RT Medical Director



I.     Purpose
       High Frequency Jet Ventilation delivers very small tidal volumes at superphysiological frequencies. As with all
       forms of ventilation, oxygenation is dependent on uniform lung inflation. HFJV achieves this by applying
       background sigh breaths for alveolar recruitment and optimal PEEP for alveolar stabilization. This strategy allows
       for lung volume recruitment without exposing the lung to high tidal volumes.

II.    Indications
       Selection criteria for initiating HFJV
       1. Airleak syndrome including PIE or unresolved pneumothorax noted on CXR.
       2. Premature infants (<35 weeks) with RDS who have received surfactant therapy and remain on conventional
           ventilator with FiO2 >0.60 for more than 4 hours.
       3. Infants > 35 weeks with OI's of 10-20.
       4. Infants with non-homogenous lung disease who have failed CMV and HFOV.
       5. Infants who have failed HFOV.

III.   Contraindications / Exclusions:
       1.   Patient is too large for HFJV (>27 kg).

IV.    Hazard/Complications
       1.   ETT obstruction – loss of Servo pressure noted, need to suction, reposition ETT, and possibly increase
            humidity.
       2.   Tracheal injury –risk of necrotizing tracheobronchitis same as CV.
       3.   Hyperventilation
            a. Monitor pCO2 with TCM if possible.
            b. Lower HFJV PIP to increase pCO2.
            c. Watch for sudden improvements in compliance by observing changes in Servo pressure.

V.     Physician / Practitioner Order
       Initiate High Frequency Jet Ventilation via HFJ Respiratory Protocol

VI.    Equipment needed
       1.   Bunnell Life Pulse High-Frequency Jet Ventilator.
       2.   Cart.
       3.   Patient Box (1 for use; 1 for standby).
       4.   HFJV Circuit Kit (Jet humidifier cartridge/circuit, tubing extension set, and a bag of sterile water).
       5.   LifePort adapter of appropriate size (2).
       6.   Oxygen Blender and Analyzer.
       7.   Conventional ventilator with the appropriate circuit and humidification system.
       8.   Transcutaneous Monitor (preferred).

VII.   Pre-Administration
            A.   Caregivers qualifications & set up
                   1. Review the policy and procedure.
                   2. Obtain training as directed by a qualified department
                   3. Be observed applying HFJV with competence for safety and proficiency as documented by
                        attending physician or a respiratory therapist experienced with HFJ Ventilation.
            B.   Check physician / practitioner order and sign off.
Neonatal Respiratory Care                                                                                  Page 2 of 4
Procedure                                     HFJV Policy and Procedure
           C.   Wash hands.
           D.   Identify patient using two patient identifiers.
           E.   Before starting HFJV, evaluate:
                   A. Chest x-ray.
                   B. Disease process – homogeneous vs. non-homogeneous; volume strategy goals (Is the lung
                         underinflated or overinflated?).
                   C. MAP on conventional ventilator (If bagging patient, divide PIP by two).

VIII. Management of patients on HFJV
      1.   The HFJV is the primary determinant of ventilation; changing HFJV PIP will control PaCO 2.

      2.   The CV background IMV rate and PEEP is the primary determinant of oxygenation; changing IMV rate will
           recruit alveoli and changing PEEP will maintain alveolar expansion. The goal for all patients is "optimal" lung
           volumes, defined as the MAP that permits the lowest FiO2. To achieve optimal lung volumes for patients with
           homogeneous lung disease and low preexisting lung volumes:
           a. Optimal lung volume is determined, to a large degree, by applying the optimal PEEP strategy (see Appendix
               A).
           b. Choose an initial CV IMV of 5-10 bpm depending on the disease process and the degree of underinflation;
               maintain alveolar inflation using a PEEP of 6-12 cm H2O depending upon the severity of the disease. HFJV
               PIP is started at  CV PIP. This strategy is appropriate for most infants with RDS.
           c. For patients with very poor compliance, it may take a higher background CV PIP level to recruit atelectatic
               alveoli (e.g., 26-34 cm H2O), but once recruited, optimal PEEP can be used to prevent loss of lung
               recruitment. The CV PIP and rate can then be weaned appropriately.
           d. As compliance improves, FiO2 should be decreased before weaning PEEP; CV PIP and Rate should be kept
               as low as possible. Clinically, improved compliance can be recognized by an increase in Servo Pressure.

           For patients with air leak or hyperinflation:
           e. Choose an initial CV IMV of 0-5 bpm depending on the severity of the airleak (closer to CPAP for severe
               airleak) and the degree to which atelectasis is a concern (up to 5 bpm for atelectasis concerns).
           f. Maintain alveolar inflation using a PEEP of 3-8 cm H2O depending upon the severity of the disease; reduce
               CV rate as PEEP is increased.
           g. HFJV PIP is started at  CV PIP. This strategy is appropriate for most infants with PIE or Ptx.
           h. Insufficient or delayed weaning of CV PIP and rate can increase the risk of airleak, including PIE and
               pneumothorax.

      3.   FiO2 – maintain O2 saturations as per NICU policy. After PEEP and background CV PIP and rate have been
           optimized, and once oxygen saturations have come into range, attempt decreasing FiO 2 as tolerated.

      4.   HFJV PIP - controlled by changing the PIP in the Controls section using the up and down arrow indicator
           buttons.
           a.  HFJV PIP =  pCO2 ;  HFJV PIP =  pCO2
           b. Press the up or down indicator until the desired PIP level is displayed.
           c. Press the ENTER button to register the desired PIP.
           d. Up to 90% of the set PIP is lost before reaching the alveoli, no matter what size ETT is being used.
           e. Depending upon the severity of the lung disease, start the PIP at = or 10%> for non-compliant lungs; start the
               PIP at = or 10%< for airleak syndromes.
               Remember that, unlike HFOV, ETT position and secretions have no effect on CWF and do not affect CO 2
               elimination. The need for ETT repositioning and suctioning will be indicated by a change in Servo pressure.
               The Servo pressure will guarantee that the desired tidal volume is delivered to the patient.
Neonatal Respiratory Care                                                                                           Page 3 of 4
Procedure                            HFJV Policy and Procedure
   IX.    Clinical Strategy with HFJ
              1. Ventilation
                 a. Manage ventilation by HFJV PIP.
                 b. The HFJV PIP is the primary determinant of pCO2.
                 c. Rule of thumb: the greater the delta P, the lower the pCO2.
                 d. Optimal PEEP to improve pO2 will also improve pCO2.
                 e. Last, consider changes in HFJV rate.
              2. Oxygenation
                 a. Follow the optimal PEEP flowchart in Appendix A.
                 b. Maintain optimal lung volumes as both overinflation and underinflation are injurious to the newborn
                      lung
                 c. Do not wean PEEP until FiO2 is  40%.
              3. Consider switching to CV or directly extubating to nasal CPAP when:
                 a. Pneumothorases and PIE are resolved (no signs on x-ray for 48-72 hours).
                 b. HFJV PIP is 14 - 18 cmH2O.
                 c. Blood gases stabilized.
              4. Treatment of Meconium Aspiration Syndrome (MAS)
                 a. Consider HFJV for infants with OI = 10-20*
                                       *OI (oxygen index) = MAP X FiO2 X 100
                                                              PaO2
                 b. Use lower HFJV rate (280-380 bpm) to avoid gas trapping
                 c. Use higher PEEP (8-12 cm H2O) to “splint” airways and allow meconium to evacuate in the swirling
                      HFJV expiratory flow.

      X.      Procedure
              Safety Assessment (prior to the initiation of the Life Pulse on a patient, a ventilator self test must be performed.)
              A.       With a circuit, test lung, and gas sources connected, depress the TEST button in the Controls section.
              B.       Observe the Test procedure until completion.
              C.       If the Life Pulse passes the Test procedure it is ready to be applied to the patient.
              D.       If the Life Pulse does not pass the Test procedure:
                       1.        Perform diagnostics as outlined in the Troubleshooting Guide of the Operator's Manual.
                       2.        Call the Bunnell Hotline at 1-800-800-HFJV (4358).
              Patient Connections
                       1.        Uncap the Jet port on the LifePort or tracheal tube and connect it to the green Jet nozzle on the
                                 circuit.
                       2.        Uncap the clear pressure monitoring line on the LifePort or tracheal tube and connect it to the port
                                 on the Patient Box labeled TO PRESSURE MONITORING LUMEN.
              Starting the Life Pulse
                       1.        Allow conventional ventilator pressures to equilibrate in the monitoring section of the Life Pulse.
                       2.        Set the parameters in the Life Pulse Controls section for PIP, Rate, and Jet Valve On-Time.
                       3.        Press the button labeled ENTER in the Controls section of the Life Pulse.
                       4.        Adjust the conventional ventilator PIP to a level that does not cause interruptions of the delivered
                                 breaths from the Life Pulse.
                       5.        Reduce the conventional ventilator rate to 0-10 breaths per minute (0-5 bpm if airleaks are the
                                 major concern; 5-10 bpm if atelectasis is the major concern).
                       6.        Establish the appearance of the READY light illuminated above the Alarms section of the Life
                                 Pulse.

XI.        Clinical Monitoring
              A. The caregiver will continuously monitor patient heart rate (HR), BP, and mean arterial pressure if
                 available while noting capillary fill time.
              B. ABG within 1 hr after initiation and after any major change and prn.
              C. Continuous SpO2 for oxygen saturation.
              D. Transcutaneous Monitor to trend CO2 if available.
              E. CXR as needed.
              F. Suctioning will be performed as needed via Ballard Suction Catheter (Special Order Part number:                 ).
Neonatal Respiratory Care                                                                                  Page 4 of 4
Procedure                                    HFJV Policy and Procedure
XII. Documentation
          A. All items on HFJV Worksheet shall be documented into the computer chart after patient stabilization.
          B. Worksheet charting shall be completed every two hours with e-charting done Q4.
          C. Worksheet does not go into the patient chart.
XIII. References
          A. Goldsmith, J. & Karotkin, E. (2003). Assisted Ventilation of the Neonate (5th ed.). Philadelphia:
             Saunders.
          B. Keszler M, et al. Multicenter controlled clinical trial of high-frequency jet ventilation in preterm infants
             with uncomplicated respiratory distress syndrome. Pediatrics 1997; 100:593-599.
          C. Carlo, W. A. (2001). Assisted Ventilation. In M. Klaus & A. Fanaroff, (Eds.), Care of the High-Risk
             Neonate, (5th ed., p. 277 - 300). Philadelphia: W.B. Saunders Company.
          D. Bunnell Incorporated, (2002). In-service Manual for the Life Pulse High Frequency Jet Ventilator.
          E. Bryan AC, Slutsky AS. Lung volume during high frequency oscillation. Am Rev Resp Dis. 1986; 133: 928-
             930

				
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