POLICY The physician orders High Frequency Jet Ventilation (HFJV). The Respiratory Therapist in discussion with the physician will determine blood gas targets and ventilation settings for the treatment of critically ill infants. The Life Pulse HFJV provides lung protection by delivering very small tidal volumes, at high frequencies, resulting in transitional flow. Transitional flow allows the HFJV to ventilate effectively at lower pressures. The Life Pulse also uses passive exhalation, which enhances mucociliary clearance. High Frequency Jet Ventilation (HFJV): Set-Up And Initiation Procedure With The Draeger Babylog VN500 Ventilator must be completed by 2 Respiratory Therapists. Applicability: Neonatal Intensive Care Unit (NICU), Neonatal Program Indications: Conventional Mechanical Ventilation (CMV) causes excessive distention of airways o Air leak syndromes such as pulmonary interstitial emphysema, pneumothorax, tracheobronchial fistula o Air trapping (meconium aspiration) Non-homogenous lung disease Hemodynamic compromise (where lower mean airway pressure (Paw) is required) Conventional mechanical ventilation is inadequate / maxed out o Carbon dioxide retention and oxygenation failure such as severe Respiratory Distress Syndrome (RDS), Pulmonary Hypoplasia, Persistent Pulmonary Hypertension of the Newborn (PPHN) Patients with copious secretions PROCEDURE Gather Equipment: Bunnell Life Pulse High Frequency Jet Ventilator (HFJV) and the Draeger Babylog VN500 ventilator cart with oxygen and air tanks Life Pulse HFJV patient circuit, patient box and water feed set with self-closing clamp Draeger Babylog VN500 (Fisher & Paykel (F&P) Infant Respiratory Care System Evaqua 2 RT 265) ventilator circuit and neonatal flow sensor Sterile water 1000 milliliter (ml) bag x 2 Transcutaneous Partial Pressure Carbon Dioxide (TcpCO 2 ) monitor INOMax connectors (15 millimeter (mm) Inner Diameter (I.D.) connector, one-way valve, ino sample tee, 15mm x 4.5mm I.D. connector x 2) JET and VN500 test lung Oxygen analyzer and oxygen T-piece Appropriate size Life-Port Endotracheal Tube (ETT) Adaptor Appropriate size closed manifold suction catheter JET Cart Drawer Checkout: o Life Pulse HFJV patient circuit x1 o Draeger Babylog VN500 ventilator circuit x1 o Patient Box x1 o JET and VN500 Test Lung x1 of each o Life Port Adapters (1 of each size) Page 1 of 7
o o JET Guidelines and Set-up Procedure Spare manifold suction connector pieces in Ziploc bag Set-Up Procedure 1. Attach high pressure oxygen and air hoses and plug in power bar to wall outlet. 2. Check air and oxygen tanks located at the back of the JET cart, to ensure they are full. 3. Ensure the JET and VN500 are both plugged into the battery. The battery and the F&P humidifier should plug into the power bar. Plug the power bar into the wall outlet. 4. Circuit the VN500, power on, and perform the device check and breathing circuit check with the neonatal flow sensor and test lung in place. 5. Remove the neonatal flow sensor from the circuit and turn off the neonatal flow sensor monitoring: a. Press the neonatal flow sensor tab on VN500 screen. b. Under the neonatal flow sensor tab, turn proximal monitoring off. c. Very gently cover the VN500 flow sensor and cable with a sterile bag. Coil the cable and softly tuck up on the middle hook of the cart. 6. Circuit the JET with Life Pulse HFJV Patient Circuit. 7. Set-up Life Pulse HFJV Patient Circuit for ino delivery: a. Connect INOMax connectors for where the INOMax DS injector module will be placed. This is between the gas outlet and the humidifier. b. Insert the one-way valve between where the injector module would be placed and the humidifier. Notes Perform a visual site to source check, to ensure all high pressure hoses are attached to the appropriate place. See Instructions for use Infinity Acute Care System Babylog VN500 Ventilation Unit SW 2.n for breathing circuit and device check on the VN500 ventilator. Press PUSH TO LOAD on patient box to install Life Pulse HFJV Patient Circuit. The placement of the one way valve prevents any water from backing up into the injector module if the JET is either put in STANDBY or cycled off. Ensure red arrow on the one-way valve is pointing toward the JET humidifier (direction of gas flow). Page 2 of 7
c. Connect the INOMax sample tee between the patient box and the end of the circuit, where the life port adaptor would connect. INOMax Sample Tee Caution: If the set dose of ino is below 5ppm and the servo pressure is 2.0psi or less, this will result in flow rates outside of the specification of the injector module and fluctuating NO values may result. 8. Attach JET test lung to the Life Pulse HFJV Patient Circuit and the patient box via the pressure line. Leave test lung open to air. 9. Turn JET ON. 10. Perform Systems Test: a. Press TEST and verify 3 clicks as JET runs through test sequence. b. Return to STANDBY once complete, then press alarm silence. 11. Perform Functional Test: a. Press ENTER. b. Press WAIT for water pump. c. Verify default settings: i. Peak Inspiratory Pressure (PIP) 20 cmh 2 O ii. Respiratory Rate (RR) 420 bpm iii. Inspiratory Time (Ti) 0.02 sec iv. Measured Positive End Expiratory Pressure (PEEP) 0+/- 1.0 cmh 2 O d. Verify READY light on within 60 seconds. Observe that all numbers light up between 1 through 9 and there are no high priority alarms. Page 3 of 7
12. Put JET in STANDBY and remove JET test lung. 13. Analyze the blender, to make sure it is correct: a. Turn on oxygen analyzer. b. Calibrate oxygen analyzer to room air. c. Turn flow meter to 10 LPM. d. Set blender to 0.5 FiO 2. e. Oxygen analyzer should be within 3% of blender. f. Once confirmed, turn off the analyzer and blender flow meter. If not going on patient immediately, ensure water bag is not connected, and pump is on WAIT. This will prevent water from entering the circuit. The VN500 has an internal oxygen analyzer (no need for an external oxygen analyzer). The JET does not have an internal oxygen analyzer and the external oxygen analyzer does not have the capacity to measure HFJV therefore a pre-use check of the blender is necessary to verify its precision. The blender can be verified at any time if there seems to be a concern. Initiation Procedure 1. Set-up procedure should be fully completed before starting the initiation procedure. 2. Ensure TcpCO 2 monitoring of patient prior to initiating HFJV. 3. Water bag set-up: a. Connect sterile water bag to F&P humidifier (VN500). b. Connect the sterile water bag to the JET humidifier via the water feed set. c. Turn on F&P Humidifier. 4. In STANDBY, set up the following on the VN500 ventilator on cart: a. Pressure Control Continuous Mandatory Ventilation (PC-CMV) mode with Volume Guarantee (VG) off. Use similar settings the patient is currently on. Set slope to 0.0. b. FiO 2 must always be set the same on VN500 and the JET Blender. Notes JET and VN500 cart should be attached to an electrical source. All high pressure hoses correctly attached. Both ventilators ON and in STANDBY. See Transcutaneous CO 2 Monitoring Policy and Procedure. The VN500 water bag is gravity fed and must be placed on the top hook. The Life Pulse JET water bag should be placed on the bottom hook since it works via pump action. Do not place on top hook as there is potential for the cartridge to overfill and pop open. Set pressure to the pressure generated during VG. FiO 2 dial and blender need to always be set the same in order to prevent dilution of oxygen delivery to the patient. If a change in oxygen is required, both the FiO 2 dial and blender need to be adjusted to the same oxygen concentration. Page 4 of 7
5. Attach the appropriate size Life Port ETT Adaptor to the Life Pulse HFJV Patient Circuit and the patient box via the pressure line. Life Port The following is the appropriate Life Port Adaptor size for ETT: ETT Size Life Port ETT Adaptor 2.5 2.5 3.0 3.0 3.5 3.5 4.0 4.5 4.5 4.5 6. Attach the appropriate size closed manifold suction catheter to the VN500 circuit and Life Port Adaptor. At this point, the suction catheter, JET circuit, VN500 circuit and Life Port Adaptor should all be connected. See Suction Policy and Procedure for HFJV. 7. Exchange patient s ETT adaptor with Life Port Adaptor, and switch patient over to the VN500 ventilator on the JET cart. Start ventilation on the VN500. 8. While JET is in STANDBY, allow 30-40 seconds for measured JET PIP, PEEP and Paw, delivered by the VN500, to stabilize. 9. Utilize the HFJV Initiation Guideline to input the following settings on the JET: PIP, RR, and Ti. Keep patient wye and original ETT adaptor in a sterile bag, taped to ventilator. This step is meant to break the circuit only once to maintain FRC. Document measured JET PIP, PEEP and Paw on the back of the Respiratory Therapy Flowsheet, in Respiratory Notes. This will allow for a quicker startup process when initiating the JET ventilator. At this point, note your desired JET settings and Sigh breath settings, using the HFJV Initiation Guideline. Document desired settings on the back of the Respiratory Therapy Flowsheet, in Respiratory Notes. Page 5 of 7
10. Ensure this step is read completely prior to commencing JET ventilation. Initiate JET Ventilation: a. Press ENTER to start JET ventilation. b. Adjust JET settings quickly as per the HFJV Initiation Guideline. c. Adjust your conventional settings on the VN500 as per the HFJV Initiation Guideline (+/- Sigh breaths). See HFJV Initiation Guideline. Once you start the JET you will quickly have to change your conventional settings to establish Sigh breaths. If not initiating Sigh breaths, ensure the VN500 mode is changed to CPAP/PS, with PS = 0, Slope = 0. 11. Continue HFJV Initiation Guideline. Document ventilation settings on Respiratory Therapy Flowsheet. Post Procedure Note 12. X-ray with infant s head and body in a SERVO pressure and TcPCO 2 should be neutral position, to confirm ETT placement documented with each blood gas. and adequate Paw, ideally within the first hour of initiating therapy. 13. Blood Gas ideally within the first hour, after settings have stabilized. 14. When appropriate, utilize the Finding Optimal Paw During HFJV Guideline and HFJV Maintenance, Escalation, and Weaning Guideline. Document Reason/justification for beginning HFJV ventilation Infant s tolerance and response to procedure Document both CMV and JET set and measured values Blood gas targets DOCUMENTATION Respiratory Therapy Ventilation Flowsheet Physician s Progress Notes Patient Safety Learning System (PSLS) if patient concern or harm occurred as a result of changing therapy Nursing Flowsheet REFERENCES Bunnell Inc. (2016) ino & HFJV Setup instructions. Retrieved from http://www.bunl.com/ino--hfjv.html Bunnell Inc. (2016) ino & HFJV Schematics. Retrieved from http://www.bunl.com/ino--hfjv.html Bunnell Inc. (2016). Clinical Resources. Retrieved from http://www.bunl.com/clinical-resources.html Bunnell Inc. (2016). Life Pulse High Frequency Ventilator In-Service Manual. Retrieved from http://www.bunl.com/uploads/4/8/7/9/48792141/inservicemanual.pdf Page 6 of 7
Drager Medical GmbH. (2012). Instructions for use Infinity Acute Care System: Babylog VN 500 Ventilation Unit SW 2.n: Operational Manual. Germany: Drager. Ikaria, Inc. (2012). INOmax DSIR (Delivery System) Operational Manual. Retrieved from http://inomax.com/wp-content/uploads/2015/01/20010_rev_05_inomax_dsir_operation_manual_with_links.pdf Section Head, Neonatology. (2007). Practice Guidelines Women s Health Program: Mechanical ventilation in newborns. (section: women s/child health programs newborn: 80.275.553). Winnipeg, MB. Health Sciences Centre. Page 7 of 7