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3100B Ventilator
3100B Ventilator
•Approved for sale outside the
US in 1998 for patients
weighing > 35 kg failing CMV
•Approved September 24, 2001
by the FDA for sale in the US
VIASYS Healthcare, Inc.
Pulmonary Injury Sequence
• There are two injury zones
during mechanical
ventilation
• Low Lung Volume
Ventilation tears
adhesive surfaces
• High Lung Volume
Ventilation overdistends, resulting in
“Volutrauma”
• The difficulty is finding the
“Safe Window”
Froese AB, Crit Care Med 1997; 25:906
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High Frequency Ventilation
• Advantages• Enables ventilation
above the “closing
volume” with lower
alveolar pressure
swings.
• Safe way of using
“Super PEEP”.
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Theory of Operation
• Controls for Oxygenation and Ventilation are
mutually exclusive.
• Oxygenation is primarily controlled by the Mean
Airway Pressure (Paw) and the FiO2.
• Ventilation is primarily determined by the stroke volume
(Delta-P) and the frequency of the ventilator.
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Large Patient Strategies
• When to consider HFOV use?
• As with all candidates, the earlier the better
• FiO2 >60, PEEP>10 with PaO2/FiO2 ratio<200
• Relative contra-indications
• Obstructive lung disease
• Elevated ICP
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Acute Respiratory Distress Syndrome
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19 yo female - Pneumococcal pneumonia (Day 1)
FiO2 100%, PEEP 20, PIP 60, SpO2 80%
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19 yo female - Pneumococcal pneumonia (Day 2)
FiO2 100% SpO2 - 78%
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19 yo female - Pneumococcal pneumonia (Day 3)
FiO2 100% and SpO2 70%
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What if physiologic goals can’t be met
using lung protective strategies?
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Large Patient Strategies
• ARDS
• FiO2 matched
• Paw 5 cmH2O above CMV
• Power of 4.0 and then adjust for good CWF
• Bias flow >20 lpm, higher if required to maintain Paw
• Frequency determined by patient size and compliance
• I-Time set to 33%
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Oxygenation Strategies
•  Paw until you are able to FiO2 to 60% with
a SaO2 of 90%
• Avoid hyperinflation
• Optimize preload, myocardial function
Ventilation Strategies
– CWF- adjust Power Setting to target PaCO2 to
between 45-55 mmHg
–  frequency by 1Hz increments if Amplitude is
maximized
– Induce cuff leak
– allow permissive hypercarbia if indicated,
keeping pH>7.25
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HFOV Strategy
• If CO2 retention persists,
decreasing cuff pressure
to allow gas to escape
around the ET tube will
move the fresh gas
supply from the wye
connector to the tip of
the ET tube
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Clinical Tips
• Failure Criteria
• Inability to decrease FiO2 by 10% within the first 24
hrs.
• Inability to improve ventilation or maintain ventilation
(after optimizing both frequency and amplitude) with
PaCO2 < 80 with pH > 7.25.
• A transcutaneous monitor is useful for trending CO2.
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Clinical Assessment
• Suctioning
• Indicated by decreased or absence CWF, decrease in O2
saturation, or an increase in TcCO2.
• Remember that each time the patient is disconnected
from HFOV, they will potentially de-recruit lung volume.
• Closed suction catheters may mitigate
• de-recruitment
• It may be necessary to temporarily  Paw or perform
recruitment maneuver
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Derecruitment during Disconnect
• Minimize suction
•
attempts
• Use closed suction
systems
• Avoid unnecessary
disconnects
• May require RM or
FiO2 to return SaO2
to baseline
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Clinical Assessment
• Chest Wiggle factor (CWF) must be evaluated upon
initiation and followed closely after that.
• CWF absent or becomes diminished is a clinical sign
that the airway or ET tube is obstructed.
• CWF present on one side only is an indication that the
ET tube has slipped down a primary bronchus or a
pneumothorax has occurred. Check the position of the
ET tube or obtain a CXR.
• Reassess CWF following any position change.
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Clinical Assessment
• Chest X-rays
• Obtain the first x-ray at the (4) hour mark to
determine the lung volume at that time. Paw
may need to be re-adjusted accordingly.
• Always obtain a CXR , if unsure as to whether
the patient is hyper-inflated or has de-recruited
the lung.
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Clinical Assessment
• Auscultation
• Breath sounds-listen to the “intensity or sound”
that the piston makes, it should be equal
throughout.
• Heart Sounds - stop the piston, (the patient is
now on CPAP); listen to the heart sounds
quickly, and restart the piston.
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Clinical Tips
• Weaning • Wean FiO2 for arterial saturation > 90%
• Once FiO2 is 60% or less, re-check chest x-ray and if
appropriate inflation, begin decreasing the Paw in
1cmH2O increments
• Wean Delta-P in 5 cmH2O increments for PaCO2
• Once the optimal frequency is found, leave it alone
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Aerosol Therapy
• Patients who are actively wheezing or have
RAD
• administration via bagging- try to
coordinate with suctioning
• IV terbutaline for patients who do not
tolerate disconnects
• promising new nebulizer technology
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Practical Considerations
• Humidification of bias flow accomplished with a
traditional heated humidifier
• Longer, flexible circuit allows patient positioning to
prevent skin breakdown
• Infection control issues
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Managing Large Patients
• Most patients will require heavy sedation
and occasional neuromuscular blockers to
be maintained on the 3100B.
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HFOV Management
Guidelines for Transition to CMV
• Paw < 24 cmH2O or stalled
• FiO2 < 50% or stalled
• > 4 days HFOV
• Return to CMV at similar Paw
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3100B Rescue Trial
• Fort P, et al. High-frequency oscillatory ventilation for
adult respiratory distress syndrome-a pilot study.
Crit Care Med 1997; 25:937-947
• Seventeen patients failing inverse ratio ventilation
recruited for rescue with HFOV (3100B)
• Predicted mortality > 80 percent
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3100B Rescue Trial
Fort P, Crit Care Med 1997; 25:937
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3100B Rescue Trial
Fort P, Crit Care Med 1997; 25:937
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Multicenter Oscillator ARDS Trial
• Prospective Randomized Controlled Trial of the
SensorMedics 3100B HFOV for adults with ARDS
• Follow-up to MOAT Pilot Rescue Trial
• Early Entry, Non-Crossover Trial
• Ten Institutions, North American Study
Derdak, AJRCCM 2002
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Patient Demographics - Baseline
N
Age
Kg
Apache II
Sepsis
Pneumonia
Trauma
Immune Compromised
Airleak
HFOV
75
48 (17)
78 (25)
22 (6)
47%
19%
21%
12%
16%
CV
73
51 (18)
81 (26)
22 (9)
47%
16%
18%
14%
19%
*NS
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Ventilator Strategies - Goals
• Normalize lung volume
• Minimize peak ventilator pressures
• Physiological targets included:
• Oxygen Saturation > 88%
• Delay weaning mPaw until FiO2 < 50%
• pH > 7.15
• PaCO2 in the range of 40 – 70 mmHg
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Primary Outcome: Status at 30d
N
Died
Alive + RS
Alive - no RS
HFOV
CMV
75
37%*
41%**
21%
73
52%
22%
26%
*P=0.098
** HFOV 61% on vent vs CMV 73% on vent
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MOAT2 - Secondary Outcomes
HFOV(n=75)
 Blood Pressure
Airleak
O2 Failure (OI >42 after 48h)
pH < 7.15
Mucus Plug
0%
9%
5%
5%
5%
CV(n=73)
3%
12%
8%
8%
4%
*NS
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MOAT2 Conclusions
• Based on a study of 148 patients, use of HFOV
for the treatment of severe ARDS resulted in an
absolute reduction in mortality by 15%.
• This reduction trend in mortality is still recognizable
at six months in this same population.
• There may also be benefits related to chronic lung
change as reflected by the small but extended use
of respiratory support in the conventional ventilation
managed patients.
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MOAT - Comparison with ARDSnet
MOAT
30d mortality
P/F
Paw
PEEP
OI
Sepsis
37%
114
22
13
24
47%
ARDSnet (6ml/kg)
31%
138
17
9
12
27%
ARDS NET, NEJM 2000
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Changing Medical Practice
• Changing Medical Practice is the Most Difficult Task
• 6 ml/kg tidal volume ventilation for ARDS
Compliance with LPV
Day 0
Day 3
Day 7
Before publication
3%
6%
9%
After publication
1%
3%
7%
• Reasons of Non-Compliance
• Reluctance to give up control to a protocol
• Patient comfort
• Acidosis
• Oxygenation
• Therefore:
• Most patients with ARDS are not managed
with LPV
• HFOV has the potential to remove most
barriers to use of LPV
Rubenfeld GD et al ATS 2001
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A Prospective Trial of HFOV in Adults with ARDS
• Patient Population
• 23 Adults
10F, 13M
• Age
48 + 15 yrs
• Weight
72 + 17 kg
• Apache II
21 + 7
• LIS
3.4 + 0.6
• Diagnosis
• Pneumonia/Sepsis
12
• Burn
5
• Bone Marrow Transplant
4
• Other
2
Mehta et al. CCM 2001;1360-1369
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A Prospective Trial of HFOV in Adults with ARDS
• Patient Population
• Prior Vent Days
• PaO2/FiO2 (mm Hg)
• OI (FiO2 xPaw x 100/PaO2)
• Pressures during CMV
• PIP (cmH2O)
• Paw
• PEEP
6.1 + 5.6 days
100 + 41
33 + 20
37 + 4
24 + 3
13.8 + 2.4
Mehta et al. CCM 2001;1360-1369
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A Prospective Trial of HFOV in Adults with ARDS
• Outcomes
• Reason for HFOV withdrawal
– Successfully weaned
10
– Withdrawal of life support/death
11
– Technical problem
2
• ICU Survival
7/23 (30%)
– Nonburn patients
7/17 (41%)
– Burn patients
0/5
Mehta et al. CCM 2001;1360-1369
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A Prospective Trial of HFOV in Adults with ARDS
• Days of Prior Ventilation
• Non Survivors
7.8 + 5.8 days
• Survivors
1.6 + 1.2 days
Mehta et al. CCM 2001;1360-1369
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HFOV in Adults with ARDS
• 42 patients failing CMV
• Baseline P/F ratio = 99(+46) increased to
191(+121) after 24 hours without HFOV related
adverse events.
• 30 day mortality was 43%
• Subset analysis showed higher 30 day mortality
in patients on CMV>3 days(67%)
M David et al ICM July,2003
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Rescue Therapy with HFOV: Don’t wait too late
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Adjunctive Therapies - iNO
• Post hoc analysis of 108 pediatric patients in a RCT
with AHRF and iNO
• Comparisons
• HFOV plus iNO (n=14)
• HFOV alone (n=12)
• CMV plus iNO (n=35)
• CMV alone (n=38)
Dobyns CCM 2002;30(11):2425
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Conclusions
• P/F ratio greatest in the HFOV plus iNO group at
4 and 12 hours
• After 24 hours, both the HFOV plus iNO and HFOV
alone resulted in greater P/F ratio improvement
• Speculation that enhanced lung recruitment by HFOV
enhances the effects of iNO on gas exchange
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Adjunctive Therapies - Proning
• Case report
• 56 yo man d/w drug overdose and aspiration failing CMV
and iNO
• transitioned to HFOV plus iNO with improved ventilation
• proning (q 6-8h) initiated due to worsening oxygenation
• transitioned to CMV post 4 days, iNO weaned after 9 days
• patient subsequently weaned and discharged
Anesthesiology 2001;95(3)797
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Unresolved Issues
•
•
•
•
•
•
What is the best way to set Paw
What are the best recruitment strategies
How are hemodynamic parameters best assessed
How are aerosols best delivered
How to best predict responders
Does HFOV result in less VILI than a conventional lung
protective strategy
VIASYS Healthcare, Inc.
Take Home Messages
• Ventilation Strategies do affect patient outcomes
• Volume and pressure swings promote lung injury
and mediator release.
• Identify patients at risk for developing VILI earlybefore the fibroproliferative stage
• Alternative therapies such as HFOV may offer
lung protection that may improve outcomes for
patients with ARDS
VIASYS Healthcare, Inc.